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

Editorial Commentary: Hip Arthroscopy Evolution and Causes of Failure

Hip arthroscopy use has grown as a result of expanding indications; improved imaging including higher resolution magnetic resonance imaging with stronger magnetic fields and the advent of 3-dimensional computed tomography revealing the nuances of hip joint morphology; increased specialized training; improvements in instruments and implants; a record of successful outcomes; and increased understanding of microinstability, focal acetabular undercoverage or occult dysplasia, indications for labral reconstruction and capsular plication, and, most of all, femoroacetabular impingement syndrome, the leading diagnosis for which hip arthroscopy is performed, in the orthopaedic community as well as the general medical and athletic communities. We now know that labral repair results in better outcomes than labral debridement, and evidence suggests that capsule closure leads to better long-term success. Osteoarthritis and its correlate, advanced age, result in inferior survivorship after hip arthroscopy, which is unsurprising; hip preservation surgery is not designed to treat irreparable cartilage damage. Association of female sex with hip arthroscopy failure requires additional investigation. More females undergo hip arthroscopy than males, and females initially present with greater disability. Females tend to have smaller alpha angles, greater femoral and acetabular anteversion, and lower center edge angles than males, consistent with increased prevalence of hip dysplasia. Thus surgeons indicating females for hip arthroscopy should be aware of atypical locations of cam lesions, borderline dysplasia, or ligamentous laxity, all of which must be appropriately respected at the time of surgery. With all of the improvements we have made in techniques, patient diagnosis and surgical indications, and our overall understanding of complex anatomy and a technically challenging surgery, we can speculate that our long-term survivorship will only improve. I await with interest the long-term outcomes we will see 10 years from today, with the addition of insight from patient-reported outcome measures to answer these questions with greater certainty.

Hip Arthroscopy for Femoroacetabular Impingement: Minimal Clinically Important Difference Rates Decline From 1- to 5-Year Outcomes

Purpose

To correlate patient-reported outcomes (PROs) and minimal clinically important difference (MCID) achievement rates after hip arthroscopy for femoroacetabular impingement syndrome (FAI).

Methods

Patients with clinically diagnosed FAI who underwent primary hip arthroscopy from September 2012 to March 2014 with a minimum of 5-year outcomes were identified. Patients undergoing labral debridement, microfracture, bilateral procedures, with evidence of dysplasia, Tönnis grade >1, and joint space <2 mm were excluded. Analysis of variance was used to compare PROs. Survival rates were determined using Kaplan–Meier analysis. Regression analysis identified associations with modified Harris Hip Scores (mHHS), minimal clinically important difference (MCID) rates, and Nonarthritic Hip Scores (NAHS).

Results

A total of 85 of 101 eligible consecutive patients (84% inclusion) (age: 41.4 ± 14.0 years; 69% female, mean body mass index [BMI] 25.0 ± 4.2) met inclusion and exclusion criteria. Patients underwent labral repair (100%) and a combination of cam (86%) and pincer resection (99%). The 5-year survival-to-revision rate was 77% whereas 5-year survival rate to total hip arthroplasty was 94%. The 1-year (87.4 ± 13.6) and 5-year (84.5 ± 13.5) mHHS scores were greater versus preoperative scores (46.3 ± 11.3, P < .001). There was a decrease in MCID rate between 1-year (n = 74, 87%) and 5-year (n = 61, 73%, P = .019) outcomes. The 1-year (87.4 ± 12.7) and 5-year (89.2 ± 15.8) NAHS scores were greater versus preoperative scores (49.7 ± 12.7, P < .001). Regression demonstrated associations between BMI (MCID: P = .033; NAHS: P = .010), age (mHHS: P = .031), and cam resection (mHHS: P = .010) with 5-year outcomes.

Conclusions

There is a decline in MCID at 5-year follow-up after hip arthroscopy for FAI. Lower BMI, younger age, and cam resection are associated with positive outcomes. There is excellent index procedure survivability and excellent total hip arthroplasty prevention rate.

Level of Evidence

Level IV.

Consensus-based classification system for intra-operative management of labral tears during hip arthroscopy-aggregate recommendations from high-volume hip preservation surgeons

The purpose of this study was to survey high-volume hip preservation surgeons regarding their perspectives on intra-operative management of labral tears to improve decision-making and produce an effective classification system. A cross-sectional survey of high-volume hip preservation surgeons was conducted in person and anonymously, using a questionnaire that is repeated for indications of labral debridement, repair and reconstruction given the torn labra are stable, unstable, viable or non-viable. Twenty-six high-volume arthroscopic hip surgeons participated in this survey. Provided the labrum was viable (torn tissue that is likely to heal) and stable, labral debridement would be performed by 76.92% of respondents for patients >40 years of age and by >84% of respondents for stable intra-substance labral tears in patients without dysplasia. If the labrum was viable but unstable, labral repair would be performed by >80% of respondents for patients ≤40 years of age and > 80% of respondents if the labral size was >3 mm and located anteriorly. Presence of calcified labra or the Os acetabuli mattered while deciding whether to repair a labrum. In non-viable (torn tissue that is unlikely to heal) and unstable labra, labral reconstruction would be performed by 84.62% of respondents if labral size was <3 mm. The majority of respondents would reconstruct calcified and non-viable, unstable labra that no longer maintained a suction seal. Surgeons performing arthroscopic hip labral treatment may utilize this comprehensive classification system, which takes into consideration patient age, labral characteristics (viability and stability) and bony morphology of the hip joint. When choosing between labral debridement, repair or reconstruction, consensus recommendations from high-volume hip preservation surgeons can enhance decision-making.

Postless Hip Arthroscopy: A Safer Alternative for Treatment of Femoracetabular Impingement Syndrome

Background

Hip arthroscopy for femoroacetabular impingement (FAI) syndrome continues to gain popularity and indications for its use are expanding. Though low complication rates have previously been reported, there are iatrogenic complications specific to the use of the perineal post, such as pudendal nerve injuries, and possible pressure skin necrosis that warrant concern in the healthy young patient. The risk of these complications are increased during simultaneous bilateral hip arthroscopy.

Indications

We describe a new technique, which will prevent such problems by using a postless pink pad technique in order to achieve adequate hip distraction.

Technique Description

Arthroscopic investigation begins with proper, safe patient positioning in order to gain access to the hip joint with sufficient joint distraction. In the postless technique, a dense foam pad is utilized in lieu of a perineal post. The static friction between the pad, bed, and the patient counters the manual gross traction necessary to distract the hip joint while preventing the patient from sliding down or off of the operating table. The postless technique avoids pressure to the perineum and also allows for greater range of motion during dynamic intraoperative examination and femoroplasty. After hip distraction, standard portal placement allows for access to the central compartment in order to assess intraarticular pathology. Once identified on diagnostic arthroscopy, appropriate techniques are utilized to correct acetabular-sided pincer lesions, labral tears, and femoral-sided cam deformities.

Results

When discussing this technique with patients, it is important to highlight that it diminishes the possibility of iatrogenic pressure injury to the pudendal nerve and skin of the perineum. The risk of these injuries typically occurs when the pudenal nerve is compressed against the post during traction and abduction. As such, postless technique prevents any compression and pressure to these regions.

Discussion/Conclusion

Hip arthroscopy is a minimally invasive, low morbidity technique for treating a variety of chondral, ligamentous, and bony conditions of the hip. However, studies suggest that pudenal nerve injury is seen in up to 4.3% of patients following hip arthroscopy. Given avoidance of iatrogenic post complications, we describe a postless technique for achieving hip distraction during hip arthroscopy.

Defining the Maximum Outcome Improvement of the Modified Harris Hip Score, the Nonarthritic Hip Score, the Visual Analog Scale For Pain, and the International Hip Outcome Tool-12 in the Arthroscopic Management for Femoroacetabular Impingement Syndrome and Labral Tear

PURPOSE

To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following hip arthroscopy for femoroacetabular impingement syndrome and labral tear, and to identify preoperative predictors of reaching the mHHS, NAHS, VAS, and the iHOT-12 thresholds for achieving the MOI.

METHODS

An anchor question was provided to patients who underwent hip arthroscopy between April 2008 and April 2019. Patients were included if they answered the anchor question and had minimum 1-year follow-up. Patients were excluded if they had a previous ipsilateral hip surgery, a Tönnis grade >1, hip dysplasia, or a previous hip condition. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. Multivariate logistic regression was used to determine predictors of achieving the MOI threshold.

RESULTS

In total, 407 hips (375 patients) were included, with 279 female patients (68.6%). The average age, body mass index, and follow-up time were 38.8 ± 13.7 years, 26.6 ± 5.8, and 51.8 ± 33.2 months, respectively. Satisfaction with the current state of their hip was reported in 77.9% (317) of the cases. It was determined that 54.8%, 52.5%, 55.5%, and 55.8% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, VAS, and iHOT-12, respectively. Predictors of achieving MOI were not identified.

CONCLUSIONS

Following hip arthroscopy in the context of femoroacetabular impingement syndrome and labral tear, the thresholds for achieving the MOI for the mHHS, NAHS, VAS for pain, and iHOT-12 were 54.8%, 52.5%, 55.5%, and 55.8% respectively. No preoperative predictors of achieving the MOI were identified.

LEVEL OF EVIDENCE

IV, case-series.

Lower body mass index and age are predictive of improved pain and health utility scores following arthroscopic management of femoroacetabular impingement

PURPOSE

To identify patient factors associated with improved pain scores, functional hip scores, health-related quality of life, and re-operation rates after arthroscopic management of femoroacetabular impingement (FAI).

METHODS

Using the comprehensive dataset from the multinational Femoroacetabular Impingement Randomized Controlled Trial (FIRST), a total of 13 prognostic factors that were chosen a priori were identified that would be expected to predict post-surgical outcomes. The primary outcome was pain assessed using a Visual Analogue Scale (VAS) and secondary outcomes included hip function (Hip Outcome Score [HOS] and International Hip Outcome Tool [iHOT-12]), health-related quality of life (Short Form-12 [SF-12] and Euro-Qol 5 Dimensions [EQ-5D]), and re-operation rate. A multivariable linear regression was used to analyse the change questionnaire scores from baseline to 12 months post-surgery including all 13 prognostic factors as independent variables. A total of 27 re-operation events were analysed at 24 months using a multivariable logistic regression including only the treatment group variable.

RESULTS

Of the 154 patients that had VAS scores completed at 12 months, a lower BMI (adjusted mean difference [aMD], 4.48 for a 5-unit decrease in BMI; 95% confidence interval [CI] 0.33-8.63; p = 0.035) was significantly associated with less pain. There was a significant negative association between increasing age and 1-year EQ-5D scores (aMD, - 0.04 for every 10-year increase in age; 95% CI - 0.07 to - 0.006; p = 0.020). The degree of impingement, severity of osteoarthritis, type of procedure, and adjudicated quality of surgery were not significantly associated with improvement across all outcomes at 12 months. Furthermore, there was no significant association between the treatment variable and the incidence of re-operation at 24 months.

CONCLUSION

This study identified that lower BMI and age are predictive of improved pain and health utility scores, respectively, following arthroscopic management of FAI at 12 months post-surgery. These results may be a helpful adjunct in clinical decisions for this patient population when determining candidacy for surgical intervention.

LEVEL OF EVIDENCE

I.

Preoperative risk factors in hip arthroscopy

PURPOSE

Arthroscopic surgery is a usual technique to repair hip femoroacetabular impingement. Correlation exists among surgical indication, postoperative evolution, the final result, and the necessity of prosthesis in the near future. The assessment of specific parameters allowing us to evaluate the prognosis becomes vital to improve the results. The objective of this study is to check the variables found in patients with femoroacetabular impingement (FAI) treated with hip arthroscopy, and determine which of these variables would serve as key indicators in predicting the need for subsequent arthroplasty.

METHODS

Data from FAI surgical indications (age, weight, height, BMI, gender, side, radiographic Tönnis degree, cartilage lesion degree by Acetabular Labrum Articular Disruption (ALAD) degree, VAS value, HOS, mHHS and WOMAC) were collected from cases which should have had a minimum monitoring period of 2 years from 2007 to 2017. The results of the group which needed prosthesis were compared to the results of the ones who did not.

RESULTS

Among 452 patients who were monitored for an average of 5.8 years, 82 (18.1%) required conversion to prosthesis. The variables that indicated relatively high risk were fourth-degree acetabular labrum articular disruption (ALAD) chondral injury, preoperative radiographic Grade 2 Tönnis classification, age of over 55 years, WOMAC over 45 points, and HOS-ADL under 50 points. There were no significant differences between side, gender, VAS level, nor HOS.

CONCLUSIONS

The presence of chondral injuries such as acetabular labrum articular disruption (ALAD) 4, radiographic Grade 2 Tönnis classification, higher age, higher BMI, and worse WOMAC, along with mHHS and HOS-ADL preoperative results, are factors which lead to a poor prognosis following FAI hip arthroscopic surgery, increasing the risk of prosthetic conversion in the short or medium term.

LEVEL OF EVIDENCE

Level IV.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction

Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

Risk of Conversion to Arthroplasty After Hip Arthroscopy: Validation of a Published Risk Score Using an Independent, Prospectively Collected Database

BACKGROUND

Hip arthroscopy is rapidly advancing and increasingly commonly performed. The most common surgery after arthroscopy is total hip arthroplasty (THA), which unfortunately occurs within 2 years of arthroscopy in up to 10% of patients. Predictive models for conversion to THA, such as that proposed by Redmond et al, have potentially substantial value in perioperative counseling and decreasing early arthroscopy failures; however, these models need to be externally validated to demonstrate broad applicability.

PURPOSE

To utilize an independent, prospectively collected database to externally validate a previously published risk calculator by determining its accuracy in predicting conversion of hip arthroscopy to THA at a minimum 2-year follow-up.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 1.

METHODS

Hip arthroscopies performed at a single center between November 2015 and March 2017 were reviewed. Patients were assessed pre- and intraoperatively for components of the THA risk score studied-namely, age, modified Harris Hip Score, lateral center-edge angle, revision procedure, femoral version, and femoral and acetabular Outerbridge scores-and followed for a minimum of 2 years. Conversion to THA was determined along with the risk score's receiver operating characteristic (ROC) curve and Brier score calibration characteristics.

RESULTS

A total of 187 patients (43 men, 144 women, mean age, 36.0 ± 12.4 years) underwent hip arthroscopy and were followed for a mean of 2.9 ± 0.85 years (range, 2.0-5.5 years), with 13 patients (7%) converting to THA at a mean of 1.6 ± 0.9 years. Patients who converted to THA had a mean predicted arthroplasty risk of 22.6% ± 12.0%, compared with patients who remained arthroplasty-free with a predicted risk of 4.6% ± 5.3% (P < .01). The Brier score for the calculator was 0.04 (P = .53), which was not statistically different from ideal calibration, and the calculator demonstrated a satisfactory area under the curve of 0.894 (P < .001).

CONCLUSION

This external validation study supported our hypothesis in that the THA risk score described by Redmond et al was found to accurately predict which patients undergoing hip arthroscopy were at risk for converting to subsequent arthroplasty, with satisfactory discriminatory, ROC curve, and Brier score calibration characteristics. These findings are important in that they provide surgeons with validated tools to identify the patients at greatest risk for failure after hip arthroscopy and assist in perioperative counseling and decision making.

Achievement of Meaningful Clinical Outcomes Is Unaffected by Capsulotomy Type During Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: Results From the Multicenter Arthroscopic Study of the Hip (MASH) Study Group

BACKGROUND

Capsule management has emerged as an important topic in the field of hip arthroscopy. The 2 most popular techniques are interportal capsulotomy and T-type capsulotomy, but few studies have compared outcomes between these 2 techniques.

PURPOSE

To compare 2-year (±2 months) patient-reported outcomes (PROs) between patients who underwent interportal versus T-type capsulotomy during arthroscopic labral repair for femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of a large multicenter registry of patients undergoing arthroscopic hip preservation surgery for FAIS was performed. Data from 9 surgeons across 9 sites between January 2014 and February 2018 were included in the study. Baseline demographic data, preoperative PROs, and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sports Subscale (HOS-SS), modified Harris Hip Score, and International Hip Outcome Tool-12 (iHOT-12) were recorded. Patients were divided into 2 groups based on whether interportal or T-type capsulotomy was performed according to the senior surgeon's preference and training, and all capsulotomies were then routinely repaired. The 2 groups were matched 1:1 by age, sex, and body mass index (BMI). Achievement of minimal clinically important difference (MCID), Patient Acceptable Symptomatic State (PASS), and substantial clinical benefit (SCB) was compared for the HOS-ADL, HOS-SS, and iHOT-12 between the 2 groups.

RESULTS

The final analysis included 658 of 1483 eligible patients with a mean ± SD age of 32.6 ± 11.6 years and BMI of 24.0 ± 3.7; of these, 329 patients were treated via interportal capsulotomy, and 329 patients were treated via T-type capsulotomy. Female patients comprised 66.3% of the study population. Capsulotomy type was not a predictor of 2-year postoperative PROs on multivariate linear regression analysis when adjusted for covariates. Chi-square analysis showed no statistical difference in achievement of MCID, PASS, and SCB between the interportal and T-type groups for HOS-ADL (80.3%, 75.8%, 52.7% and 77.1%, 71.7%, 53.6%, respectively; P > .01 for all), HOS-SS (83.6%, 72.5%, 51.5% and 81.7%, 68.4%, 49.2%, respectively; P > .01 for all), and iHOT-12 (87.5%, 72.0%, 50.5% and 80.0%, 64.7%, 45.6%, respectively; P > .01 for all).

CONCLUSION

Arthroscopic management of FAIS resulted in significant clinical improvement that was independent of capsulotomy type when the capsulotomy included repair.

Mid- to Long-Term Outcomes of Hip Arthroscopy: A Systematic Review

PURPOSE

To assess mid- to long-term patient-reported outcomes (PROs) of hip arthroscopy as well as the rates of secondary surgery and to identify indications for surgery and noted predictors of failure.

METHODS

A systematic review of the current literature was performed with the terms "hip arthroscopy," "outcomes," "patient-reported outcomes," "mid-term," "5-year," "long-term," and "10-year" in the PubMed, Cochrane, and Embase databases in April of 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data for study characteristics, patient demographics, follow-up time, indications for surgery, PROs, predictors of failure or unfavorable PROs, and rates of secondary hip preservation surgery and conversion to total hip arthroplasty were collected.

RESULTS

Thirteen articles were included. Four studies were level III and 9 were level IV. In total, 1571 hips were included, and the average follow-up time ranged from 60 to 240 months. The most common indications for hip arthroscopy were labral tears and femoroacetabular impingement syndrome. Twelve studies reported on PROs and all reported improvement at latest follow-up. The most reported on scores were the modified Harris Hip Score, Harris Hip Score, and the Hip Outcome Score-Sport Specific Subscale. When grouped based on average follow-up time, the conversion rates at the 5- and 10-year time points ranged from 3.0% to 17.9% and 2.4% to 32.5%, respectively. One study with 20-year follow-up reported a conversion rate of 41.0%. Osteoarthritis and increased age were the most cited predictors for secondary surgery or decreased PROs.

CONCLUSIONS

At mid- to long-term follow-up, patients who underwent primary hip arthroscopy demonstrated improvement in several PROs. There was great variability in rates for revision surgery and conversion to total hip arthroplasty. The most common indications for hip arthroscopy were labral tears and femoroacetabular impingement syndrome. Osteoarthritis and increased age were the most cited predictors for unfavorable outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III and IV studies.

Defining the Clinically Meaningful Outcomes for Arthroscopic Treatment of Femoroacetabular Impingement Syndrome at Minimum 10-Year Follow-up: The Timing of Surgery Is Crucial

Background

Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) has become a common procedure. However, meaningful long-term clinical outcomes have not been defined.

Purpose

To define the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptomatic state (PASS) for the modified Harris Hip Score (mHHS) at a minimum 10-year follow-up in patients undergoing arthroscopic treatment for FAIS and identify preoperative predictors for achievement of the MCID, SCB, and PASS.

Study Design

Case-control study; Level of evidence, 3.

Methods

A consecutive series of patients undergoing arthroscopic treatment for FAIS between 2007 and 2009 with a minimum 10-year follow-up was analyzed. Patient data included patient characteristics, radiographic parameters, and the pre- and postoperative mHHS and visual analog scale (VAS) for pain score. Paired t tests were used to compare the patient-reported outcome measures (PROMs). The MCID was determined by calculating half of the standard deviation, and SCB and PASS were calculated by the anchor method. Correlation and logistic regression analyses were conducted to identify predictors for the achievement of the MCID, SCB, and PASS.

Results

A total of 44 patients (27 men, 17 women) were included. The mean age and body mass index were 42.2 years (range, 16-67 years) and 22.3 kg/m² (range, 16.76-29.78 kg/m²), respectively. The MCID, absolute SCB, net change SCB, and PASS of the mHHS were calculated to be 19.6, 90.1, 31.5, and 84.4 points, respectively. Preoperative symptom duration was identified as an independent predictor for the achievement of meaningful clinical outcomes. The median symptom durations for patients who achieved the MCID, absolute SCB, net change SCB, and PASS were 11.7, 9.1, 9.0, and 10.8 months, respectively. The median symptom duration for patients who did not achieve the MCID, absolute SCB, net change SCB, and PASS were 15.8, 17.4, 17.3, and 18.4 months, respectively. No other statistically significant correlations were found.

Conclusion

The preoperative duration of symptoms was identified as an independent predictor for achievement of the MCID, SCB, and PASS. These findings can be helpful in accelerating the transition to surgical treatment of FAIS.

Allocation of Anchors During Labral Repair: A Multicenter Cohort Analysis of Labral Treatment in Hip Arthroscopy

Background:

While previous studies have established several techniques for suture anchor repair of the acetabular labrum to bone during arthroscopic surgery, the current literature lacks evidence defining the appropriate number of suture anchors required to effectively restore the function of the labral tissue.

Purpose/Hypothesis:

To define the location and size of labral tears identified during hip arthroscopy for acetabular labral treatment in a large multicenter cohort. The secondary purpose was to differentiate the number of anchors used during arthroscopic labral repair. The hypothesis was that the location and size of the labral tear as well as the number of anchors identified would provide a range of fixation density per acetabular region and fixation method to be used as a guide in performing arthroscopic repair.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

We used a multicenter registry of prospectively collected hip arthroscopy cases to find patients who underwent arthroscopic labral repair by 1 of 7 orthopaedic surgeons between January 2015 and January 2017. The tear location and number of anchors used during repair were described using the clockface method, where 3 o’clock denoted the anterior extent of the tear and 9 o’clock the posterior extent, regardless of sidedness (left or right). Tear size was denoted as the number of “hours” spanned per clockface arc. Chi-square and univariate analyses of variance were performed to evaluate the data for both the entire group and among surgical centers.

Results:

A total of 1978 hips underwent arthroscopic treatment of the acetabular labrum; the most common tear size had a 3-hour span (n = 820; 41.5%). Of these hips, 1645 received labral repair, with most common repair location at the 12- to 3-o’clock position (n = 537; 32.6%). The surgeons varied in number of anchors per repair according to labral size (P < .001 for all), using 1 to 1.6 anchors for 1-hour tears, 1.7 to 2.4 anchors for 2-hour tears, 2.1 to 3.2 anchors for 3-hour tears, and 2.2 to 4.1 for 4-hour tears.

Conclusion:

Variation existed in the number of anchor implants per tear size. When labral repair involved a mean clockface arc >2 hours, at least 2 anchor points were fixated.

The Efficacy of Labral Reconstruction: A Systematic Review

Background:

With a greater understanding of the importance of the acetabular labrum in the function of the hip, labral repair is preferred over debridement. However, in some scenarios, preservation or repair of the labrum is not possible, and labral reconstruction procedures have been growing in popularity as an alternative to labral resection.

Purpose:

To provide an up-to-date analysis of the literature to determine the overall efficacy of labral reconstruction when compared with labral repair or resection.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

PubMed, Embase, and MEDLINE databases were searched for literature regarding labral reconstruction in the hip before July 21, 2020. The results were screened and evaluated by 2 reviewers, and a third reviewer resolved any discrepancies. The final studies were evaluated using the MINORS (Methodological Index for Non-randomized Studies) score.

Results:

There were 7 comparative studies that fit the inclusion criteria, with 228 hips from 197 patients. The mean follow-up was 34.6 months, and the mean age of all patients was 38.34 years. There were slightly more female patients than male patients (105 vs 92). Arthroscopic reconstruction was performed in 86% of studies (6/7); open surgical techniques, in 14% (1/7). A variety of grafts was used in the reconstructions. The indications for labral reconstruction and outcome measures varied in these publications. Nine patients were lost follow-up, and 6 patients converted to total hip replacement postlabral reconstruction. The assessment of these comparative studies illustrated statistically equivalent results between labral reconstruction and labral repair. Comparisons of labral reconstruction with labral resection also showed statistically equivalent postoperative patient-reported outcome scores; however, the rates of conversion to total hip arthroplasty were significantly higher in the population undergoing resection.

Conclusion:

The review of current available comparative literature, which consists entirely of level 3 studies, suggests that labral reconstruction does improve postoperative outcomes but does not demonstrate superiority over repair. There may, however, be benefit to performing labral reconstruction over resection owing to the higher rate of conversion to total hip arthroplasty in the labral resection group.

Midterm Follow-Up and Assessment of Cartilage Thickness by Arthro-Magnetic Resonance Imaging After Arthroscopic Cam Resection, Labral Repair, and Rim Trimming Without Labral Detachment

PURPOSE

To evaluate the clinical and radiological outcome, sum of acetabular and femoral cartilage thickness, and rate of failure in the midterm after arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair, and rim trimming without labral detachment.

METHODS

This retrospective case series included patients with FAI syndrome who had undergone hip arthroscopy from January 2009 to December 2010 by a single surgeon, with a minimum follow-up of 55 months. Data from patients who had undergone arthroscopic hip procedures with labral repair, rim trimming, and femoral osteoplasty were analyzed pre- and postoperatively. Clinical outcome (nonarthritic hip score [NAHS], Short Form 36 [SF-36]), range of motion, progression of osteoarthritis (Tönnis grade), radiological parameters (α angle, lateral center-edge angle [LCEA], Tönnis angle), femoral and acetabular cartilage thickness (using magnetic resonance imaging [MRI]), and intraoperative findings were evaluated.

RESULTS

Of 148 hip arthroscopies performed, 97 included rim trimming, labral refixation, and femoral osteoplasty. Ten cases were lost to follow-up, leaving 87 hips. Arthroscopic revision was performed on 4 hips and total hip replacement on 4 hips, and 1 hip underwent both arthroscopic revision and total hip replacement. Excluding these 9 cases of revision, for which follow-up was not possible (retrospective study), the remaining 78 hips were followed up for a minimum of 55 months (77 ± 11.4, mean ± SD; range 55 to 124). Mean NAHS (65 to 88, P < .001), SF-36 physical subscale (65 to 85, P < .001), and the numerical pain rating scale (NRS) (5 to 1, P < .001) improved significantly. Outcome scores of minimal clinical importance (NAHS) were achieved in 67.6% of the patients. Mean range of movement improved significantly in flexion (109 to 122, P < .001) and internal rotation (10 to 22.7, P < .001). NAHS was positively associated with flexion of the hip postoperatively (r = 0.307, P = .011). In 16 cases, microfracture was performed (15 acetabular and 1 femoral). Preoperative α angles (anteroposterior and modified Dunn) were significantly higher in this cohort (P < .001, 95% confidence interval 8.9 to 25.2, P = .001). Twenty hips (28 %) progressed to worse Tönnis grades. Initial Tönnis grades were grade 0, 38; grade 1, 48; grade 2, 8. Pre- or postoperative Tönnis grades did not show any correlation with pre- or postoperative NAHS and NRS. MRI measurements at the latest follow-up (69 patients) of the femoral and acetabular cartilage thickness did not reveal any significant reduction at the 12 o'clock position.

CONCLUSION

Arthroscopic cam resection, rim trimming, and labral repair without detachment of the labrum provides good or excellent outcome in 77.1% of hips based on NAHS in the midterm. Higher range of motion in flexion is associated with higher NAHS postoperatively. Arthroscopic cam resection, rim trimming and labral repair without detachment of the labrum is a successful method for the treatment of FAI syndrome in the midterm.

LEVEL OF EVIDENCE

IV, retrospective case series.

Treatment of Labral Calcification in the Setting of Femoroacetabular Impingement Syndrome With Arthroscopic Calcification Excision, Labral Repair, and Osteoplasty Improves Outcomes

PURPOSE

To describe the diagnosis and 2-year outcomes of arthroscopic treatment for labral calcification in the setting of femoroacetabular impingement syndrome (FAIS).

METHODS

A retrospective analysis was performed from a prospectively collected database of patients with FAIS undergoing hip arthroscopy. Patients with FAIS with labral calcification were differentiated radiographically from patients with other paralabral radiopaque densities such as os acetabuli, acetabular rim fractures, and labral ossification. Patients with FAIS with labral calcification were treated with arthroscopic calcification excision, labral repair, and osteoplasty and matched by age, sex, and body mass index with a cohort of patients with FAIS without labral calcifications who underwent labral repair and osteoplasty. Pre- and 2 years postoperatively, patients completed patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey, and visual analog scale.

RESULTS

In total, 40 hips (21 male, 19 female) with FAIS and labral calcification were included (age 36.8 ± 8.1, body mass index, 25.9 ± 4.5). Patients with FAIS with labral calcification demonstrated similar significant PRO score improvements compared with a matched cohort of patients with FAIS without labral calcification at 2 years after surgery (visual analog scale: (-)2.3 ± 0.4, (-)2.7 ± 0.5, modified Harris Hip Score: 16.1 ± 2.6, 17.1 ± 3.2; HOOS symptoms: 21.9 ± 3.7, 18.6 ± 3.6; HOOS pain: 22.1 ± 3.0, 25.0 ± 3.5; HOOS activities of daily living: 20.2 ± 2.8, 23.8 ± 3.3; HOOS sport: 35.6 ± 5.0, 35.6 ± 4.1; HOOS quality of life: 36.9 ± 4.5, 37.5 ± 4.4; 12-item Short-Form survey physical component summary: 15.5 ± 2.3, 20.1 ± 2.1, respectively). Both cohorts achieved minimal clinically important differences at equivalent rates (60%-82.5%) for all PRO scores.

CONCLUSIONS

Patients with labral calcification in the setting of FAIS can be effectively treated with arthroscopic calcification excision, labral repair, and osteoplasty. These patients demonstrate significant improvements in patient-reported outcomes and achievement of minimal clinically important differences at 2 years similar to patients undergoing arthroscopic treatment for FAIS without labral calcification.

LEVEL OF EVIDENCE

Level III, matched cohort study.

Best Practices: Hip Femoroacetabular Impingement

OBJECTIVE. Imaging plays a critical role in the assessment of patients with femoroacetabular impingement (FAI). With better understanding of the underlying pathomechanics and advances in joint-preserving surgery, there is an increasing need to define the most appropriate imaging workup. The purpose of this article is to provide guidance on best practices for imaging of patients with FAI in light of recent advances in corrective FAI surgery. CONCLUSION. Pelvic radiography with dedicated hip projections is the basis of the diagnostic workup of patients with suspected FAI to assess arthritic changes and acetabular coverage and to screen for cam deformities. Chondrolabral lesions should be evaluated with unenhanced MRI or MR arthrography. The protocol should include a large-FOV fluid-sensitive sequence to exclude conditions that can mimic or coexist with FAI, radial imaging to accurately determine the presence of a cam deformity, and imaging of the distal femoral condyles for measurement of femoral torsion. CT remains a valuable tool for planning of complex surgical corrections. Advanced imaging, such as 3D simulation, biochemical MRI, and MR arthrography with application of leg traction, has great potential to improve surgical decision-making. Further research is needed to assess the added clinical value of these techniques.

Femoroacetabular Impingement and Management of Labral Tears in the Athlete

Femoroacetabular impingement and associated labral tearing is a common source of hip pain in athletes. This article reviews the hip joint anatomy and complex interplay between alterations on the femoral and acetabular sides, in addition to evaluation of soft tissue stabilizers and spinopelvic parameters. Symptom management with a focus on arthroscopic treatment of abnormal bony morphology and labral repair or reconstruction is discussed. In select patients with persistent pain who have failed conservative measures, hip arthroscopy with correction of bony impingement and labral repair or reconstruction has yielded good to excellent results in recreational and professional athletes.

Hip Arthroscopy for Femoroacetabular Impingement in Adolescents: 10-Year Patient-Reported Outcomes

BACKGROUND

Previous studies have demonstrated hip arthroscopy to be an effective treatment for femoroacetabular impingement (FAI) in individuals 18 years of age and older. Long-term outcome data in the adolescent population, however, are limited.

PURPOSE

To report 10-year outcomes after hip arthroscopy in adolescents with symptomatic FAI.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Prospectively collected data were analyzed on adolescent patients younger than 18 years of age who had hip arthroscopy between March 2005 and 2009 with a minimum 10-year follow-up. Patients were included if they were diagnosed with symptomatic FAI and an associated labral tear that was treated with repair. Patients were excluded if they had previous hip procedures, acetabular dysplasia (lateral center-edge angle, <20°), avascular necrosis, previous hip fracture or dislocation, or Legg-Calve-Perthes disease, or refused to participate. The primary patient-reported outcome measure was the Hip Outcome Score (HOS) Activities of Daily Living (ADL) subscale. In addition, the HOS-Sport, modified Harris Hip Score (mHHS), 12-Item Short Form Health Survey (SF-12), and patient satisfaction were collected. Failure was defined as patients having to undergo revision arthroscopy.

RESULTS

There were 60 patients (70 hips) who met inclusion criteria and had a 10-year follow-up. The mean age of the cohort was 16 ± 1.2 years, with 21 male and 49 female hips. Seven hips (10%) required revision hip arthroscopy. All revisions occurred in female patients and were associated with global laxity as well as longer duration of symptoms before time of surgery. At a mean follow-up of 12 years (range, 10-14 years), patients who did not undergo revision surgery had significant improvements from preoperatively to postoperatively in HOS-ADL (from 64 to 92; P < .01), HOS-Sport (from 40 to 86; P < .01), mHHS (from 56 to 88; P < .01), and SF-12 Physical Component Summary (from 41 to 54; P < .01). The median patient satisfaction was 10 out of 10 (very satisfied).

CONCLUSION

Hip arthroscopy for FAI with labral repair resulted in excellent patient-reported outcomes and satisfaction at a minimum of 10 years of follow-up. There was a 10% rate of revision surgery, which was associated with global laxity and longer duration of symptoms before surgery, which should be considered in patient selection.

Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence?

BACKGROUND

With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020.

METHODS

Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies.

RESULTS

Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23).

CONCLUSION

Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.

Hip Arthroscopy for Femoroacetabular Impingement: 1-Year Outcomes Predict 5-Year Outcomes

BACKGROUND

Limited evidence exists comparing short- and long-term patient-reported outcomes (PROs) and overall survival rates after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

HYPOTHESIS

Patients with high improvement (HI) versus low improvement (LI) at 1 year postoperatively would achieve higher PROs and better index procedure survival rates at 5-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopy for FAIS between September 2012 and March 2014 with minimum 5-year outcome data were identified. Using the median 1-year change in modified Harris Hip Score (mHHS) as a threshold, HI and LI subcohorts were determined. Analysis of variance was used to compare PROs. Failure rates were determined using Kaplan-Meier and Cox proportional hazards model analyses. Regression analysis was used to identify factors associated with increasing 5-year change in mHHS and Nonarthritic Hip Score (NAHS).

RESULTS

Out of 108 eligible consecutive patients, 89 (82.4%) were included (mean [SD]: age, 43.3 [14.6] years; body mass index, 25.4 [4.5]). As compared with the LI group (n = 45), the HI group (n = 44) had a longer 5-year index surgery survival rate (mean ± SEM: 83.7 ± 3.3 months vs 68.5 ± 4.6 months; P = .012) and 5-year estimated survival rate (89% vs 71%). The HI group had a decreased risk of failure versus the LI group (hazard ratio, 0.15; P = .002). The HI group also had greater PROs than did the LI group at 1 year (mHHS: 94.8 ± 1.2 vs 72.6 ± 2.7, P < .001; NAHS: 94.0 ± 1.3 vs 75.6 ± 2.2, P < .001) and 5 years (mHHS: 86.9 ± 2.0 vs 77.6 ± 3.4, P = .017; NAHS: 92.6 ± 1.8 vs 82.7 ± 4.1, P = .020). As compared with the LI group, the HI group achieved higher rates of the Patient Acceptable Symptomatic State (PASS) and minimal clinically important difference (MCID) at 1 year (PASS: 95% vs 42%, P < .001; MCID: 100% vs 89%, P = .056) and 5 years (PASS: 77% vs 45%, P = .002; MCID: 86% vs 64%, P = .014). Linear regression demonstrated that being in the HI group (ΔmHHS, P = .041; ΔNAHS, P = .017) and decreasing body mass index (ΔmHHS, P = .055; ΔNAHS, P = .023) were associated with higher 5-year ΔPROs.

CONCLUSION

Patients with FAIS and significant improvement in the first year after hip arthroscopy had superior 5-year outcomes versus patients with persistent symptom severity. Survival rates and PROs were significantly better in patients who achieved high early outcomes at the 1-year mark.

No Correlation Between Depth of Acetabuloplasty or Postoperative Lateral Center-Edge Angle on Midterm Outcomes of Hip Arthroscopy With Acetabuloplasty and Labral Repair

BACKGROUND

The treatment of pincer deformity in hip arthroscopy remains controversial, with some authors advocating that over resection may risk early joint deterioration. The role of acetabular resection depth and postoperative acetabular morphology on postoperative outcomes has yet to be defined.

PURPOSE/HYPOTHESIS

This study measures the influence of acetabular resection depth and postoperative lateral center-edge angle (LCEA) on minimum 5-year patient-reported outcomes (PROs), revision rates, and conversion to total hip arthroplasty using a single surgeon's prospective database. We hypothesized that patients with acetabular resections >10°, as measured by LCEA, or patients with postoperative LCEA outside the normal range of 25° to 35° would have lower PROs, higher revision rates, and higher conversion to total hip arthroplasty at midterm follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A total of 192 patients who underwent primary hip arthroscopy with acetabuloplasty and labral repair by a single surgeon with a minimum 5-year follow-up met the inclusion criteria. Preoperative and postoperative LCEAs were measured on supine anteroposterior radiographs, and patients were divided into cohorts based on LCEA and acetabular resection depth. Cohorts for postoperative LCEA were <20° (dysplasia), 20° to 25° (borderline dysplasia), 25° to 35° (normal), and >35° (borderline overcoverage). Cohorts for acetabular resection depth were <5°, 5° to 10°, and >10° difference from preoperative to postoperative LCEA. Outcome measures included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), 12-Item Short Form Health Survey, modified Harris Hip Score, Hip Outcome Score, satisfaction scores, revision rates, and conversion to arthroplasty rates.

RESULTS

Patients significantly improved in all outcome score measures at final follow-up. There were no statistically significant differences in PRO scores or conversion to total hip arthroplasty between any cohorts in the postoperative LCEA group. There were more revisions in the 25° to 35° cohort than the other cohorts (P = .02). The 5-10° resection depth cohort demonstrated a higher postoperative WOMAC score (P = .03), but otherwise no statistically significant differences were seen between resection depth cohorts in the remaining postoperative outcomes scores, revision rates, or conversion to total hip arthroplasty rates.

CONCLUSION

Patients with postoperative LCEA values outside the normal reference range and with large resections perform similar to those with normal postoperative LCEA values and smaller resections at a minimum 5-year follow-up.

Decreased Hip Labral Width Measured via Preoperative Magnetic Resonance Imaging Is Associated With Inferior Outcomes for Arthroscopic Labral Repair for Femoroacetabular Impingement

PURPOSE

To determine the association between labral width as measured on preoperative magnetic resonance imaging (MRI) and hip-specific validated patient self-reported outcomes at a minimum of 2 years' follow-up.

METHODS

We performed an institutional review board-approved retrospective review of prospectively gathered hip arthroscopy patients from 2010 to 2017. The inclusion criteria were defined as patients aged 18 to 65 years with radiographic evidence of femoroacetabular impingement who underwent a primary labral repair and had a minimum of 2 years' clinical follow-up. The exclusion criteria were defined as inadequate preoperative imaging, prior hip surgery, Tönnis grade 1 or higher, or lateral center-edge angle lower than 25°. An a priori power analysis was performed. MRI measurements of labral width were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clock-face" locations using a previously validated technique. Outcomes were assessed using the Harris Hip Score (HHS), modified Harris Hip Score (mHHS), and Non-arthritic Hip Score (NAHS). For the mHHS, scores of 8 and 74 were used to define the minimal clinically important difference and patient acceptable symptomatic state, respectively. Patients were divided into groups by a labral width less than 1 SD below the mean (hypoplastic) or widths above 1 SD below the mean. Statistical analysis was performed using linear and polynomial regression; the Mann-Whitney U, χ², and Fisher exact tests; and intraclass correlation coefficient testing.

RESULTS

A total of 103 patients (107 hips) met the inclusion criteria (mean age, 39.4 ± 17 years; body mass index, 25.0 ± 4; 51% right sided; 68% female patients; mean follow-up, 76.5 ± 19.1 months [range, 30.0-113.0 months]). Mean labral width at the 11:30 clock-face position (indirect rectus), 3-o'clock position (psoas U), and 1:30 clock-face position (point halfway between the 2 aforementioned positions) was 7.1 ± 2.2 mm, 7.0 ± 2.0 mm, and 5.5 ± 1.9 mm, respectively. Intraclass correlation coefficient agreements were good to excellent between readers at all positions (0.83-0.91, P < .001). The preoperative HHS, mHHS, and NAHS were not statistically significantly different (P > .05) between the 2 groups. Sex, laterality, and body mass index were not predictive of outcomes (P > .05). The postoperative HHS, mHHS, and NAHS were found to be significantly lower in the hypoplastic group at each location tested (P < .01), including the mHHS at the 11:30 clock-face position (69 vs 87), 3-o'clock position (70 vs 87), and 1:30 clock-face position (71 vs 87). The proportion of patients with hypoplastic labra who reached the minimal clinically important difference was significantly lower (P < .001) at the 11:30 clock-face position (50% vs 91%), 3-o'clock position (56% vs 90%), and 1:30 clock-face position (58% vs 91%) in comparison to the non-hypoplastic labrum group. The proportion of patients with hypoplastic labra above the patient acceptable symptomatic state was significantly lower (P < .001) at the 11:30 clock-face position (44% vs 83%), 3-o'clock position (37.5% vs 84%), and 1:30 clock-face position (42% vs 85%) in comparison to the non-hypoplastic labrum group. Linear regression modeling was not significant at any position (P > .05). Polynomial regression was significant at the 11:30 clock-face position (R² = 0.23, P < .001), 3-o'clock position (R² = 0.17, P < .001), and 1:30 clock-face position (R² = 0.26, P < .004).

CONCLUSIONS

Hip labral width less than 1 SD below the mean measured via preoperative MRI was associated with significantly worse functional outcomes after arthroscopic labral repair and treatment of femoroacetabular impingement. The negative relation between labral width and outcomes may be nonlinear.

LEVEL OF EVIDENCE

Level IV, case series with subgroup analysis.

Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome, Labral Tear, and Acetabular Overcoverage: Minimum 5-Year Outcomes With a Subanalysis Against Patients Without Overcoverage

BACKGROUND

Improvement in patient-reported outcomes (PROs) has been reported in the short term after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear in the setting of acetabular overcoverage. Yet, there is a paucity of information in the literature on midterm PROs.

PURPOSE

To (1) report minimum 5-year PROs in patients who underwent primary hip arthroscopy for FAIS and acetabular labral tears in the context of acetabular overcoverage and (2) compare outcomes with those of a propensity-matched control group without acetabular overcoverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively analyzed on all patients who underwent hip arthroscopy for FAIS and labral tears between February 2008 and November 2013. Inclusion criteria were lateral center-edge angle >40° and minimum 5-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the Hip Outcome Score-Sports-Specific Subscale (HOS-SSS). Exclusion criteria were previous ipsilateral hip surgery or conditions, active workers' compensation claims, or lack of minimum 5-year outcomes. A 1:1 propensity-matched comparison was made between the study group and a control group without acetabular overcoverage (lateral center-edge angle, 25°-40°) based on age at surgery, sex, body mass index, Tönnis grade, laterality, and follow-up time. The minimal clinically important difference (MCID) was calculated for the mHHS, HOS-SSS, and NAHS. Secondary surgical procedures were recorded.

RESULTS

A total of 54 patients satisfied the inclusion criteria for the study group, of whom 45 (83.3%; 45 hips) had a minimum 5-year follow-up and were matched without differences in age at surgery, sex, body mass index, or follow-up time. The study and control groups demonstrated significant and comparable improvements for the mHHS (mean ± SD Δ, 24.06 ± 24.19 vs 26.33 ± 17.27; P = .625), NAHS (Δ, 31.22 ± 25.31 vs 27.15 ± 17.61; P = .399), and HOS-SSS (Δ, 33.16 ± 34.73 vs 34.75 ± 26.15; P = .557). The rates for achieving the MCID were similar for the study and control groups for the mHHS (76.7% vs 84.2%; P = .399), HOS-SSS (79.1% vs 75.8%; P = .731), and NAHS (81.4% vs 84.2%; P = .738). Need for revision surgery was similar (P = .748). A lower conversion rate to total hip arthroplasty was reported for the study than for the control group (2.2% vs 15.6%; P = .026).

CONCLUSION

In the context of FAIS, labral tears, and acetabular overcoverage, patients who underwent hip arthroscopy reported significant improvement in several PROs at minimum 5-year follow-up. Moreover, outcomes were comparable with those of a propensity-matched control group without acetabular overcoverage. Furthermore, the rate of achieving the MCID for the mHHS, HOS-SSS, and NAHS was similar between these groups.

Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups

BACKGROUND

Limited evidence exists concerning the effect of age on hip arthroscopy outcomes for femoroacetabular impingement (FAI).

PURPOSE/HYPOTHESIS

The purpose was to investigate patient-reported outcomes (PROs) and clinical failure rates across various age groups in patients undergoing hip arthroscopy for FAI. We hypothesized that older patients would experience lower improvements in PROs and higher clinical failure rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 109 of 130 eligible consecutive patients underwent hip arthroscopy for FAI with a minimum 5-year follow-up. Patients were stratified into 3 groups for comparison (ages 15-34, 35-50, and 51-75 years). Clinical survival rates to revision surgery or total hip arthroplasty (THA) were determined by Kaplan-Meier analysis, and PROs were assessed using analysis of variance. Regression analysis was used to determine factors associated with clinical failure and ΔPROs from baseline to 5 years.

RESULTS

The 5-year survival-to-revision rate was 71% (survival time, 69.2 months; 95% CI, 62.8 to 75.5 months). A significant difference in survival to THA was found between groups (P = .030). Being in the older group versus the young and middle-aged groups predicted increased risk of THA conversion (hazard ratio, 5.7; 95% CI, 1.1 to 28.6; P = .035). Overall modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) improved from baseline to 5 years (mHHS, P < .001; NAHS, P < .001). Body mass index (mHHS: beta, -1.2; 95% CI, -2.2 to -0.3; P = .013; NAHS: beta, -1.6; 95% CI, -2.6 to -0.5; P = .005) and baseline PROs (mHHS: beta, -0.8; 95% CI, -1.1 to -0.4; P < .001; NAHS: beta, -0.7; 95% CI, -1.1 to -0.4; P < .001) were predictive of 5-year ΔPROs. A decrease was seen in minimal clinically important difference rates in middle-aged (P = .011) and old (P = .030) groups from 6-month to 5-year outcomes.

CONCLUSION

Although hip arthroscopy for FAI yielded improvements in PROs regardless of age, middle-aged and older patients experienced greater declines in clinical outcomes over time than younger patients. Older patients remain good candidates for arthroscopy despite a greater risk for conversion to THA.

Femoroacetabular Impingement Syndrome

Femoroacetabular impingement (FAI) syndrome is one of the most rapidly evolving etiologies of hip pain. The 2016 Warwick Agreement consensus statement defined FAI syndrome as a triad of symptoms, signs, and radiographic findings. Cam morphology is more likely in athletes and is associated with repetitive hip loading in maximal flexion during adolescence. Much less is known about the development of pincer morphology. Physical therapy improves pain and function, justifying a trial before pursuing surgery. Musculoskeletal injections are utilized for FAI syndrome, but the evidence is limited. Arthroscopic surgery for FAI syndrome can correct the morphological changes and address the underlying soft tissue injuries. Recent studies evaluated reliable indicators of surgical outcomes, the most reliable of which is the presurgical presence of osteoarthritis. Recent studies demonstrate the efficacy of surgery, but with the risk of complication and no guarantee of a return to the same level of sport.

[Research progress in arthroscopic treatment of acetabular labrum injury]

Objective

To review the surgical methods of arthroscopy in the treatment of acetabular labrum injury, and to provide reference for clinical treatment.

Methods

The literature about the surgical methods and clinical results of hip arthroscopy in the treatment of acetabular labrum injury was reviewed and analyzed.

Results

In the early stages of hip arthroscopy, the removal of the torn labrum is the primary treatment option. The current principles of treatment are based on the specific circumstances of a torn labrum, including acetabular labrum debridement, acetabular labrum repair, acetabular labrum reconstruction, and acetabular labrum augmentation.

Conclusion

Hip arthroscopy has become the preferred technique for the treatment of acetabular labrum injury. Labral repair is still the first choice, and labral reconstruction is used when acetabular labrum injury cannot be repaired.

Does labral repair have a clinical benefit during arthroscopic treatment of femoro-acetabular impingement? Prospective multicentre study with 2-year follow-up

INTRODUCTION

Hip arthroscopy has emerged as an effective tool for treating labral tears associated with femoro-acetabular impingement (FAI).

OBJECTIVE

Compare the effectiveness of debridement versus labral repair on functional outcomes at 2 years after hip arthroscopy and evaluate the influence of the repair technique.

HYPOTHESIS

There is no statistical difference in short-term functional outcomes between debridement and repair. The type of repair technique has no influence on functional outcomes.

METHODS

From July 2017 to June 2018, a prospective study was done at 10 participating hospitals specialised in hip preservation surgery. Patients over 18 years of age, who underwent hip arthroscopy for a labral tear due to femoro-acetabular impingement, were enrolled. Patients underwent either labral repair or debridement. The labral repairs were performed with either the loop or mattress technique and functional outcomes were evaluated using the Non-Arthritic Hip Score (NAHS).

RESULTS

One hundred and eighty-seven patients who underwent arthroscopic treatment for FAI were enrolled; 42 (22.5%) underwent labral debridement and 145 (77.5%) underwent labral repair. In the repair group, 66 (46%) were mattress sutures and 79 (54%) were loop sutures. Mean patient age was 33.3±10.3 (18-63) and 38% of patients were women (n=71). Mean follow-up was 16.2 months (10-26.4). The mean NAHS improved from 47.3 to 72.8 (p<0.05) at final follow-up. There was no significant difference between the repair and debridement groups (p>0.05). There was no significant difference between the mattress and loop repair subgroups (p>0.05).

CONCLUSIONS

There is no statistical difference in short-term functional outcomes between debridement and repair. The type of repair technique has no influence on functional outcomes.

LEVEL OF EVIDENCE

II, prospective cohort study.

Age-Associated Pathology and Functional Outcomes After Hip Arthroscopy in Female Patients: Analysis With 2-Year Follow-up

BACKGROUND

Previous research has demonstrated a statistically significant relationship between hip arthroscopy outcomes and age.

PURPOSE

To investigate the link, if any, between hip arthroscopy outcomes and intraoperative pathology as well as with patient age and sex.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Of 272 female patients aged ≥14 years undergoing primary hip arthroscopy for femoroacetabular impingement between August 2010 and September 2017, and with 2-year patient-reported outcome scores, a total of 194 (71.3%) were included for final analysis. These patients were separated into 3 age-based cohorts: <30 years (n = 44), 30 to 45 years (n = 74), and >45 years (n = 76). Their data were then analyzed and compared with respect to patient characteristic information, intraoperative pathology, and functional outcome scores for statistical significance, which was set at P < .05.

RESULTS

When an analysis of variance was conducted for the 3 age groups at 2-year follow-up, there was a statistically significant difference for modified Hip Harris Score (P = .0003; <30 years, 88.26 ± 13.1 [mean ± SD]; 30-45 years, 82.68 ± 18.0; >45 years, 75.03 ± 19.5). The results of an analysis of variance comparing 2-year Non-arthritic Hip Score were also statistically significant (P = .0002; <30 years, 89.9 ± 13.7; 30-45 years, 85.8 ± 15.8; >45 years, 78.1 ± 17.2). Results of logistic regression demonstrated that the odds of a cam-type lesion decreased by 0.971 for every additional year in age among female patients. The odds of achieving the patient-acceptable symptomatic state decreased by a factor of 0.96 for each additional year in age (P < .0004).

CONCLUSION

Surgical treatment of femoroacetabular impingement in females led to improved functional outcomes at 2 years of follow-up, although older female patients did worse after hip arthroscopy as compared with their younger counterparts. There may be an age-dependent decrease in incidence of cam-type lesions in female patients.

Teamwork in hip preservation: the ISHA 2019 Annual Scientific Meeting

Hip preservation surgery is now an established part of orthopedic surgery and sports medicine. This report describes the key findings of the 11th Annual Scientific Meeting of International Society for Hip Arthroscopy-the International Hip Preservation Society-in Madrid, Spain from 16 to 19 October 2019. Lectures, seminars and debates explored the most up-to-date and expert views on a wide variety of subjects, including: diagnostic problems in groin pain, buttock pain and low back pain; surgical techniques in acetabular dysplasia, hip instability, femoroacetabular impingement syndrome, labral repair and reconstruction, cartilage defects, adolescent hips and gluteus medius and hamstring tears; and new ideas about femoral torsion, hip-spine syndrome, hip capsule surgery, impact of particular sports on hip injuries, registries, robotics and training for hip preservation specialists. Surgeons, sports physicians, radiologists and physiotherapists looking after young people with hip problems have an increasingly sophisticated armoury of ideas and techniques with which to help their patients. The concept of hip preservation has developed incredibly fast over the last decade; now it is clear that the best results can only be achieved by a multidisciplinary team working together. The 2020s will be the decade of 'Teamwork in Hip Preservation'.

What Is the Survivorship After Hip Arthroscopy for Femoroacetabular Impingement? A Large-database Study

BACKGROUND

Patients with femoroacetabular impingement (FAI) may experience lasting clinical improvement after hip arthroscopy; however, some patients will still eventually undergo early conversion to THA due to unresolved symptoms and progression of arthritis. However, the risk of this has been only incompletely characterized in prior studies.

QUESTIONS/PURPOSES

Using a large healthcare claims database over a 5-year period (2011-2016), we asked: (1) What is the survivorship free from THA after arthroscopic osteoplasty performed for FAI? (2) What identifiable demographic factors and patient characteristics are associated with early conversion to THA after hip arthroscopy performed for FAI?

METHODS

We included all patients who underwent hip arthroscopy for FAI, between the ages of 12 years and 63 years, with 3 months of claims data before hip arthroscopy and minimum 2-year follow-up. A total of 4730 hip arthroscopy patients from 2011 to 2014 were retrieved from a US commercial claims database. Hip arthroscopy incidence doubled over time from 1.2 to 2.1 persons per 100,000. Temporal trends, patient demographics, diagnoses at time of arthroscopy, and patient comorbidities were retrieved and logistic regression performed. Survivorship analysis on 11,323 patients (lifting the 2-year follow-up requirement) was also performed to identify independent variables associated with early risk of conversion to THA.

RESULTS

In patients undergoing hip arthroscopy for FAI, the overall proportion of conversion to THA within 2 years after hip arthroscopy was 7% (338 of 4730). After controlling for confounding variables such as sex, obesity, and depression, we found the following were independently associated with increased odds of conversion to THA: older age (odds ratio 1.08 [95% CI 1.01 to 1.10]; p < 0.001), osteoarthritis (OR 2.91 [95% CI 2.27 to 3.77]; p < 0.001), joint inflammation (OR 1.89 [95% CI 1.16 to 3.09]; p = 0.01), and a history of opioid use (OR 2.17 [95% CI 1.69 to 2.79]; p < 0.001). Survivorship analysis similarly revealed that older age (hazard ratio 1.08 [95% CI 1.07 to 1.09]; p < 0.001), osteoarthritis (HR 2.53 [95% CI 2.13 to 3.01]; p < 0.001), joint inflammation (HR 1.53 [95% CI 1.10 to 2.11]; p = 0.01), a history of opioid use (HR 2.02 [95% CI 1.71 to 2.38]; p < 0.001), and smoking (HR 1.55 [95% CI 1.14 to 2.11]; p = 0.005), were independently associated with increased odds of conversion to THA within 2 years after hip arthroscopy for FAI.

CONCLUSIONS

Although the findings of this study are limited and should not be taken in isolation, patients with FAI who are older, carry diagnoses of inflammatory or degenerative articular disease, or who use opioids or smoke should be counseled about a potentially increased risk of undergoing early conversion to THA after hip arthroscopy. Future studies to further examine the effect of these diagnoses in prospectively collected cohorts, incorporating radiographic and patient-reported outcome measures, are needed.

LEVEL OF EVIDENCE

Level III, prognostic study.

Circumferential Labral Reconstruction for Irreparable Labral Tears in the Primary Setting: Minimum 2-Year Outcomes With a Nested Matched-Pair Labral Repair Control Group

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores of primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare these PROs with a matched-pair primary labral repair group.

METHODS

Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary circumferential labral reconstruction with anterior tibialis tendon allograft during February 2016 to April 2017 for irreparable labral tears and FAIS and had preoperative and minimum 2-year follow-up for modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale, Non-arthritic Hip Score, International Hip Outcome Tool 12 (iHOT-12), 12-Item Short Form Health Survey physical component and mental component, Veterans RAND 12-Item Health Survey physical component and mental component, and visual analog scale for pain. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, Tönnis grade 2 or higher, or dysplasia (lateral center-edge angle ≤ 18°). Labral tears were considered irreparable if the labrum appeared (1) to be mostly or completely calcified and (2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was matched 1:3 based on age, sex, and body mass index to a benchmark control group of hips undergoing labral repair from the same period. The minimal clinically important difference and patient acceptable symptomatic state for the mHHS and iHOT-12 score were calculated.

RESULTS

A total of 37 hips (37 patients) underwent circumferential labral reconstruction. There were 19 female patients (51.4%) and 18 male patients (48.6%). The mean age was 45.6 ± 11.6 years, and the average body mass index was 27.1 ± 5. At minimum 2-year follow-up, the circumferential labral reconstruction group showed statistically significant improvements in the mHHS, Non-arthritic Hip Score, Hip Outcome Score-Sport-Specific Subscale, iHOT-12 score, and visual analog scale score. All hips in the reconstruction group were successfully matched to 111 labral repair hips. At latest follow-up, improvements in all PROs between the 2 groups were comparable. The revision rates were 0% and 3.6% in the reconstruction and repair groups, respectively.

CONCLUSIONS

After primary hip arthroscopy, primary circumferential labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS and irreparable labral tears resulted in significant improvements in several PROs at minimum 2-year follow-up and high patient satisfaction. Primary circumferential labral reconstruction reached comparable functional outcomes to those of a benchmark matched-pair primary labral repair control group.

LEVEL OF EVIDENCE

Level III, case-control study.

Acetabular Labral Reconstruction with Iliotibial Band Autograft: Outcome and Survivorship at a Minimum 10-Year Follow-up

BACKGROUND

Labral reconstruction has been shown to result in improved patient-reported outcomes (PROs) at mid-term follow-up in patients with a deficient labrum. The purpose of this study was to determine survivorship and PROs at a minimum 10-year follow-up.

METHODS

A retrospective evaluation of a prospectively collected single-surgeon database included 91 hips (89 patients) that underwent arthroscopic labral reconstruction with iliotibial band autograft between 2006 and 2008. The primary PRO was the Hip Outcome Score (HOS)-activities of daily living (ADL). The modified Harris hip score (mHHS), HOS-sports, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and patient satisfaction (on a scale of 1 to 10) were also collected at a 10-year minimum follow-up. Survivorship analysis curves were evaluated.

RESULTS

Eighty-two hips were evaluated at a 10-year minimum follow-up. Overall survivorship, with revision hip arthroscopy or total hip arthroplasty (THA) as the end point, was 70% at 5 years and 61% at 10 years, and the mean survival time was 9 years (95% confidence interval = 7.6 to 10 years). For the patients who did not undergo subsequent surgery, on average the mHHS increased from 60 preoperatively to 82 at the 10-year follow-up (p = 0.001), the HOS-ADL improved from 69 to 90 (p = 0.004), the HOS-sports improved from 43 to 76 (p = 0.001), and the median patient satisfaction was 10 of 10. Eighty percent of the patients achieved the minimal clinically important difference (MCID) in the HOS-ADL, and 87% obtained a patient acceptable symptom state (PASS).

CONCLUSIONS

Following arthroscopic labral reconstruction with iliotibial band autograft, 9% of the hips underwent revision arthroscopy and 27% underwent THA. At 10 years, the survival rate, with revision hip arthroscopy or THA as the end point, was 61%; however, for those with >2 mm of joint space, the current indication for labral reconstruction, the 10-year survival rate was 90%. Excellent PROs and patient satisfaction were reported by those who did not require revision or THA. With appropriate patient selection and prevention of postoperative adhesions, labral reconstruction results in excellent outcomes and high patient satisfaction that is sustained at a minimum 10-year follow-up.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R ² = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

The Hip Suction Seal, Part II: The Effect of Rim Trimming, Chondrolabral Junction Separation, and Labral Repair/Refixation on Hip Distractive Stability

BACKGROUND

The acetabular labrum contains free nerve endings, and an unstable labrum can result in increased femoral head movement during hip motion. This can be caused by chondrolabral junction (CLJ) separation, especially in association with pincer-type femoroacetabular impingement, and may contribute to hip pain.

HYPOTHESIS

Rim resection alone has no effect on suction seal biomechanics. Further, separation of the CLJ changes hip suction seal biomechanics when compared with those of the native state, whereas repair and refixation with suture anchors restore these biomechanical parameters.

STUDY DESIGN

Controlled laboratory study.

METHODS

A total of 12 fresh-frozen human cadaveric hips were used in this study. Hips were mounted in a saline bath on a dynamic tensile testing machine and were distracted at a rate of 0.5 mm/s from neutral position. A total of 3 parameters (force, displacement, and intra-articular pressure) were measured throughout testing. Before testing, hips were randomly allocated to 1 of 2 groups: 1 that included the CLJ separation (CLJ Cut group) and 1 that did not (CLJ Intact group). Hips were tested in the following states: (1) native, (2) rim trimming, (3) separated CLJ (CLJ Cut group only), and (4) labral repair/refixation. For each group a linear mixed-effects model was used to compare biomechanical parameters between states.

RESULTS

Rim trimming did not affect any suction seal parameters relative to those of the native state. In the CLJ Cut group, no significant difference in distance to break the suction seal was observed for any states compared with that of the native state. In the CLJ Intact group, the distance to break the suction seal was significantly shorter in the labral refixation state (1.8 mm) than the native state (5.6 mm; P = .002). The maximum distraction force (62.1 ± 54.1 N) and the peak negative pressure (-36.6 ± 24.2 kPa) of the labral repair/refixation state were significantly lower than those of the native state in both groups (93.4 ± 41.7 N, P = .01; -60.7 ± 20.4 kPa, P = .02).

CONCLUSION

Rim trimming did not change the biomechanical properties of the labral suction seal. Labral refixation resulted in a shorter distance to break the labral suction seal. This indicates that labral mobility is reduced by the labral refixation procedure, which could be beneficial in postoperative pain relief and labral healing.

CLINICAL RELEVANCE

The labral refixation reduced labral mobility, which could be beneficial for both pain relief and labral healing to the acetabulum after pincer-type femoroacetabular impingement resection.

Is hip arthroscopy useful in the treatment of borderline dysplasia?: a case-control study

INTRODUCTION

Since arthroscopy remains a controversial treatment of hip dysplasia, our objective was to analyse its clinical and radiological results in a cohort of patients with dysplasia and compare them to controls with femoroacetabular impingement (FAI).

MATERIAL AND METHODS

We retrospectively analysed a series of patients who underwent hip arthroscopy for the treatment of labral pathology; 29 of them with borderline hip dysplasia and 197 with FAI, comparing reoperations and joint survival. The diagnosis of borderline dysplasia was made with a lateral centre-edge angle greater than 18° but less than 25°. The average follow-up was 43 months. We performed a multivariate regression analysis to evaluate the association of reoperations with different demographic, radiological and intraoperative variables.

RESULTS

Seven complications were registered in the FAI group (1 medically treated superficial wound infection, 3 pudendal nerve paraesthesias, 1 deep vein thrombosis and 2 heterotopic ossifications) and none in the dysplasia group. While 5 patients from the FAI group required a new surgery, none of the dysplasia group was re-operated (p=.38). After adjusting for confounders, reoperation showed a very strong association with the finding of osteochondral lesions during index surgery, with a coefficient of .12 (p<.001, 95%CI=.06-.17).

CONCLUSION

Hip arthroscopy was useful in the treatment of borderline dysplasia, without non-inferior survival compared to the FAI group. We suggest indicating it carefully in dysplasia cases, whenever the symptoms of femoroacetabular friction prevail over those of instability.

Periacetabular Osteotomy for Developmental Dysplasia of the Hip and Femoroacetabular Impingement: A Study Using the U.K. Non-Arthroplasty Hip Registry (NAHR) Data Set

BACKGROUND

Periacetabular osteotomy (PAO) is a well-recognized procedure for the treatment of hip dysplasia in young adults and can be used for the surgical management of femoroacetabular impingement (FAI) with acetabular retroversion. The aim of this study was to use a national database to assess the outcomes of PAO for developmental dysplasia of the hip (DDH) and for FAI.

METHODS

All patients in whom an isolated PAO had been performed between January 2012 and February 2019 were identified in the Non-Arthroplasty Hip Registry (NAHR). Their outcomes were assessed using the EuroQol-5 Dimensions (EQ-5D) index and the International Hip Outcome Tool (iHOT)-12 preoperatively and then at 6 months, 12 months, and 2 years postoperatively.

RESULTS

Six hundred and thirty (630) PAOs were identified, with 558 (89%) performed for DDH and 72 (11%) performed for FAI. Most patients (90%) were female. The mean age in the DDH group (31.2 years) was significantly higher (p < 0.0001) than that in the FAI group (26.5 years). There were no other significant between-group demographic differences. Preoperatively and at each follow-up time-period, iHOT-12 scores were better in the DDH group than in the FAI group; however, only the preoperative scores differed significantly. There was significant improvement between the preoperative and 6-month iHOT-12 and EQ-5D index scores in both the DDH and the FAI group. This improvement was maintained at 12 months postoperatively, by which time almost 90% of the patients had achieved the minimum clinically important difference (MCID) in their iHOT-12 score.

CONCLUSIONS

This study shows that PAO is a successful surgical intervention for DDH and FAI in the short term, with significant improvement in patient-reported outcome scores that is maintained up to 2 years postoperatively.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroscopy for Femoroacetabular Impingement and Concomitant Labral Tears: A Minimum 2-Year Follow-Up Study

PURPOSE

The present study investigated the minimum 2-year outcomes of hip arthroscopy for femoroacetabular impingement (FAI) and concomitant labral tears in Asian patients.

METHODS

Patients who underwent hip arthroscopy for both FAI and concomitant labral tears between January 2012 and December 2017 were included. Patients with hip osteoarthritis of Tönnis grade ≥2, previous hip surgery, or followed for less than 2 years were excluded. Clinical assessments were performed using the modified Harris Hip Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the rates of achieving threshold values of the minimal clinically important difference and patient acceptable symptomatic state at the latest follow-up. Plain radiographs were acquired pre- and postoperatively for radiologic assessments.

RESULTS

A total of 73 patients (90 hips, 58 male, 15 female; mean age 34.4 years) who underwent hip arthroscopy for FAI and concomitant labral tears were enrolled. Forty-three hips (47.8%) had cam-type, 7 (7.8%) had pincer-type, and 40 (44.4%) had mixed-type FAI. The mean follow-up duration was 5.2 years. In cam- and mixed-type FAI hips, the mean α angle significantly decreased from 66.7 ± 8.28° preoperatively to 44.9 ± 3.78° postoperatively (95% confidence interval [CI] 19.6°-22.8°; P < .001). The mean modified Harris Hip Score and Western Ontario and McMaster Universities Osteoarthritis Index increased from 74.8 ± 13.2 and 75 ± 12.7 preoperatively to 93 ± 8.1 (95% CI 15.4-20.9; P = .001) and 89.4 ± 8.4 postoperatively (95% CI 11.8-17; P = .001), respectively. Seventy-four hips (82.2%) crossed the minimal clinically important difference, and 85 hips (94.4%) had achieved the patient acceptable symptomatic state. There were 2 cases of pudendal nerve palsy and 1 case of sciatic nerve palsy. No additional surgeries were required.

CONCLUSIONS

Hip arthroscopy can be an effective treatment for FAI and concomitant labral tears in Asian patients as demonstrated in this study, with improved PRO scores and reoperation rates. Longer-term studies with larger cohorts are necessary.

LEVEL OF EVIDENCE

Level IV, case series.

Is Labral Size Predictive of Failure With Repair in Hip Arthroscopy?

PURPOSE

To assess whether labral size is predictive of labral repair failure or shows an association with patient outcomes after hip arthroscopy.

METHODS

We performed a retrospective chart review of patients who underwent arthroscopic hip labral repair. Labral size was measured in 4 quadrants with an arthroscopic probe. The average size across torn labral segments was assessed for failure as determined by the change in patient-reported outcomes, the rate at which subjects achieved the minimal clinically important difference and patient acceptable symptomatic state, and the need for additional surgery. Outcomes were evaluated for any continuous correlation as well as significant differences between the middle 50% of labral sizes and classes of labral sizes derived from upper and lower quartile and decile ranges. Included hips were those from patients aged between 18 and 55 years with 2-year postoperative follow-up and lateral center-edge angles between 25° and 40°.

RESULTS

The study included 571 hips. Labral width did not show a significant difference between hips requiring revision and those not requiring revision (P = .4054). No significant correlation was found between labral width and the change in the International Hip Outcome Tool 12 score (R² = 0.05780), modified Harris Hip Score (R² = 0.19826), or Nonarthritic Hip Score (R² = 0.23543) from preoperatively to 2 years postoperatively. Hips with labral sizes in the upper decile of our cohort showed significantly decreased improvement in the International Hip Outcome Tool 12 score (P = .0287) and Nonarthritic Hip Score (P = .0490) compared with the middle 50% of labral sizes. No statistically significant difference was found in the rate at which the groups achieved the minimal clinically important difference or patient acceptable symptomatic state.

CONCLUSIONS

Hypertrophic labra in the largest 10th percentile showed lower postoperative outcome scores. However, no detectable clinical benefit was found in terms of patient-perceived clinical difference or acceptable symptomatic state. For most patients, labral size does not appear to significantly alter patient outcomes or the need for arthroplasty.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Influence of prior hip arthroscopy on outcomes after hip arthroplasty: A meta-analysis of matched control studies

BACKGROUND

No meta-analysis exists elucidate the impact of prior hip arthroscopy on the outcomes of subsequent hip arthroplasty. The purpose of this study was to systematically review the current evidence in the literature to ascertain if prior hip arthroscopy leads to inferior outcomes after hip arthroplasty.

METHODS

PUBMED, Scopus, EMBASE, and Cochrane Library databases were searched on May 20, 2019. Only English publications were included. The primary outcomes were postoperative complication, revision, and reoperation. Secondary outcomes included Harris Hip Score (HHS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), operative time, and estimated blood loss.

RESULTS

Eleven studies with a total of 1227 patients were included. The pooled data revealed that patients with prior hip arthroscopy were associated with higher risks for any postoperative complication (P < .00001), dislocation (P = .03), revision (P = .03), and reoperation (P = .02) following subsequent hip arthroplasty. However, there were no significant differences in infection rate (P = .22), HHS (P = .09), WOMAC (P = .19), operative time (P = .52), and estimated blood loss (P = .17) between the groups.

CONCLUSIONS

Patients with prior hip arthroscopy are at increased risks for any postoperative complication, dislocation, revision, and reoperation following subsequent hip arthroplasty. However, prior hip arthroscopy does not appear to have an impact on the functional outcomes and intraoperative outcomes.

Patient-related risk factors associated with less favourable outcomes following hip arthroscopy

AIMS

This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy.

METHODS

Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review.

RESULTS

Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers' compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy.

CONCLUSION

Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822-831.

Prospective Analysis of Arthroscopic Hip Anatomic Labral Repair Utilizing Knotless Suture Anchor Technology: The Controlled-Tension Anatomic Technique at Minimum 2-Year Follow-up

BACKGROUND

Labral tears are the most common abnormalities in patients undergoing hip arthroscopic surgery. Appropriate management is crucial, as it has been shown that better overall outcomes can be achieved with labral restoration.

PURPOSE

To report the patient-reported outcomes (PROs) at minimum 2-year follow-up of patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique in the setting of femoroacetabular impingement syndrome (FAIS).

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data were prospectively collected for patients who underwent hip arthroscopic surgery for FAIS for labral tear repair using the knotless controlled-tension anatomic technique. Patients were excluded if they had prior hip conditions, prior ipsilateral surgery, Tönnis grade >1, a lateral center-edge angle (LCEA) <25°, or workers' compensation claims. Preoperative and postoperative scores at minimum 2-year follow-up were recorded for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain. The proportion of patients who achieved the minimal clinically important difference (MCID) or patient acceptable symptomatic state (PASS) for the mHHS, HOS-SSS, and iHOT-12 were also reported.

RESULTS

A total of 309 hips were included. The mean patient age was 36.2 years (range, 12.8-75.9 years). The mean preoperative LCEA and alpha angle were 31.9° and 57.1°, respectively. A significant improvement on the mHHS (62.6 ± 15.7 preoperatively vs 86.9 ± 16.2 at 2-year follow-up), NAHS (63.1 ± 16.7 vs 86.1 ± 16.7), and HOS-SSS (39.8 ± 22.0 vs 74.2 ± 27.3) was found (P < .001 for all). A significant decrease was shown for VAS scores (P < .001). Also, 78.6% and 82.2% of patients achieved the MCID and PASS for the mHHS, respectively; 60.8% and 69.9% of patients met the MCID and PASS for the HOS-SSS, respectively; and the MCID for the iHOT-12 was met by 77.3% of patients.

CONCLUSION

In the setting of FAIS and labral tears, patients who underwent hip arthroscopic surgery for labral tear repair using the knotless controlled-tension anatomic technique demonstrated significant improvement in several validated PRO measures, the VAS pain score, and patient satisfaction at a minimum 2 years of follow-up. Based on this evidence, labral tear repair using the knotless controlled-tension anatomic technique seems to be a safe option.

First 100 segmental labral reconstructions compared to the most recent 100: the role of surgeon experience in decreasing conversion to total hip arthroplasty

PURPOSE

The purpose of this study was to determine if conversion to total hip arthroplasty and patient-reported outcomes were similar in the first 100 patients who underwent segmental labral reconstruction with iliotibial band autograft compared to the most recent 100 patients.

METHODS

Patients who underwent hip segmental labral reconstruction with autologous iliotibial band were evaluated preoperatively and postoperatively with a minimum 2-year follow-up. The first consecutive 100 patients (Group 1) and the most recent 100 patients (Group 2) were retrospectively compared. Conversion to total hip arthroplasty, necessity of a revision hip arthroscopy, and patient-reported outcome scores were compared.

RESULTS

Overall follow-up rate (> 2 years) was 94% (Group 1 vs. Group 2, 91% vs. 96%, n.s.). Mean age of Group 1 (37 ± 12) was significantly higher than that of Group 2 (34 ± 12) (p = 0.03). In Group 2, 69 surgeries out of 100 were revision hip arthroscopies, which was significantly higher rate than Group 1 (48/100) (p = 0.003). Group 1 had significantly higher rate of conversion to THA [23% (23/100) vs. 5% (5/100), p = 0.001]. Revision hip arthroscopy was performed in 11/76 (15%) in Group 1 and in 8/95 (9%) in Group 2 (n.s.). Patient-reported outcomes scores were similar between two groups (all n.s.). Higher age and joint space ≤ 2 mm were significant risk factors of total hip arthroplasty conversion.

CONCLUSION

This study showed that, with experience, fewer conversions to total hip arthroplasty were seen; however, revision rate and outcomes were similar.

LEVEL OF EVIDENCE

IV.

Does hip preservation surgery prevent arthroplasty? Quantifying the rate of conversion to arthroplasty following hip preservation surgery

Hip arthroscopic surgery for femoroacetabular impingement and periacetabular osteotomy (PAO) for dysplasia is the most commonly used contemporary treatment for these conditions and has been shown to provide pain relief and restore function. What is less understood and perhaps of more interest to health economists, is the role of these procedures in preserving the hip joint and avoiding hip arthroplasty. The aim of this systematic review was to determine whether hip joint preservation surgery, indeed, preserves the hip joint by looking at conversion rates to total hip arthroplasty (THA). Two separate searches were undertaken, using PRISMA guidelines and utilizing PubMed and Open Athens search engines, identifying manuscripts that looked at conversion to THA following either hip arthroscopy (HA) or PAO. When considering HA, we found 64 eligible papers. Out of these studies, there were 59 430 hips with 5627 undergoing conversion to THA (9.47% [95% CI 9.23–9.71%]) with a mean conversion time of 24.42 months. Regarding PAO, there were 46 eligible papers including 4862 patients who underwent PAO with subsequent conversion to THA in 404 patients (8.31% [95% CI 7.54–9.12%]). with a mean conversion time of 70.11 months. Certain features were associated with increased conversion rates, including increasing age, worsening arthritis and joint space <2 mm. This study demonstrates that the mean conversion rates to be <10% for HA and PAO, during the mean follow-up periods of included manuscripts. Joint preserving surgery appears to defer or at least delay the need for THA.

Mid-term Patient-reported Outcomes of Hip Arthroplasty After Previous Hip Arthroscopy: A Matched Case-control Study With a Minimum 5-year Follow-up

BACKGROUND

Previous hip arthroscopy may affect the outcomes of subsequent hip arthroplasty. The purpose is to compare mid-term patient-reported outcomes (PROs) and complication rates in patients who had previous ipsilateral hip arthroscopy (PA) with those without a previous surgery.

METHODS

A minimum 5-year PROs, complications, and revision surgery rates were compared between total hip arthroplasty (THA) recipients who received PA and those without. Available intraoperative findings, procedures, and conversion time of arthroscopies were reported. The relative risk (RR) of complications and revision THAs were reported. A Kaplan-Meier analysis assessed survivorship of revision THA.

RESULTS

There were 34 cases (33 patients) of PA that were matched to 89 control cases (87 patients). Both cohorts reported similar scores for Harris hip score, Forgotten Joint Score, pain, and patient satisfaction. No differences in the outcomes were found based on the arthroplasty approach. A higher postoperative complication rate {RR, 2.617 (95% confidence interval [CI], 0.808 to 8.476)} and revision THA rate (RR, 13.088 [95% CI, 1.59 to 107.99]) were found in the PA group.

CONCLUSION

Patients with PA demonstrated similar levels of PROs as those without previous ipsilateral hip arthroscopy. There may, however, be a higher rate of complications and revision surgery in the PA group.

LEVEL OF EVIDENCE

III.

Running with Femoral Acetabular Impingement: Operative Vs Nonoperative Treatment

A 31-year-old female lawyer presents with right hip pain starting approximately 3 years ago and worsening over the past 2 to 3 months. She is an avid runner, running 20 to 30 miles weekly, and noticed that her pain started after a running program training for the marathon. Her pain is primarily over the lateral aspect of her hip with some radiation into the groin. The pain is made worse with impact exercises such as running and made better with walking and cycling. She has done physical therapy for the past 3 months without any significant improvement. She has not had any injections or taken anti-inflammatories because of a history of gastric ulcer disease. On physical examination she has mild tenderness over her right greater trochanter and her range of motion tests are full in terms of flexion, internal rotation, and external rotation. She has a positive FADIR (flexion-adduction-internal rotation) impingement that causes both groin and lateral hip pain. Radiograph of the right hip revealed preservation of the joint space and an anterior cam lesion with reduced offset at the femoral head neck junction. Magnetic resonance imaging (MRI) of the right hip revealed a tear at the anterior superior labrum at the 1 to 2 o'clock position along with subjacent bone marrow edema in the femoral head that is likely reactive. Computed tomography (CT) scan of the right hip confirmed a combined cam and pincer type femoral acetabular impingement of the right hip with overcoverage of the femoral head. There was 15° of femoral anteversion and the coronal lateral center of edge angle (LCEA) is 34°. Dr. Peter Moley argues that a focused rehabilitation program to restore strength and motor control of the deep hip stabilizers will provide optimal functional recovery. Dr. Jakub Tatka argues that right hip arthroscopy with labral repair and possible osteochondralplasty are indicated in order to prevent early hip arthritis and prevent long-term sequela of femoral acetabular impingement.