Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset

Declining Postoperative 90-Day Opioid Prescriptions From 2010 to 2021 Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To analyze postoperative opioid prescriptions after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in a large, opioid-naive population and to evaluate factors associated with receiving more opioids.

Methods

Opioid-naive adult patients who underwent hip arthroscopy for FAIS were queried in the 2010 to 2022 PearlDiver Mariner 161 national administrative database. Exclusion criteria included patients with a history of chronic pain and patients who received opioid prescriptions more than 30 days before surgery. Patient variables were extracted: age, sex, and Elixhauser Comorbidity Index. Ninety-day postoperative opioid prescriptions (by total morphine milligram equivalents [MMEs]) were assessed with multivariate linear regression. Ninety-day postoperative opioid prescriptions from 2011 to 2021 were assessed.

Results

Of 27,079 patients with postoperative opioid prescriptions identified, a mean ± standard deviation of 347.6 ± 729.2 MMEs (40 tablets of 5 mg oxycodone) were prescribed per patient, with a mean of 1.6 prescriptions filled per patient within 90 days following surgery. Seventy-five percent of patients filled fewer than 600 MMEs, but a small subset filled more than 2,000 MMEs. Multivariate analysis revealed that, compared to patients in the age 30- to 39-year group, those aged 20 to 29 years received fewer MMEs (Δ = -72.5, P < .017). Compared to those with an Elixhauser Comorbidity Index of 2 or under, those >2 were prescribed more MMEs (Δ = 52.5, P < .017). Sex did not correlate with the postoperative MMEs prescribed. From 2011 to 2021, a 58.2% decrease in the 90-day mean MMEs prescribed was noted per patient (P < .017).

Conclusions

Fewer postoperative MMEs were filled following FAIS hip arthroscopy for patients in their 20s relative to those in their 30s, as well as for those with lower comorbidity burden. Patient sex was not associated with differences in postoperative MMEs prescribed. The amount of mean MMEs prescribed per patient decreased from 2011 to 2021.

Clinical Relevance

This study provides information about the typical amount of narcotics required after surgery. This is increasingly useful information, as surgeons/clinicians continue to try to minimize the role of narcotics in postoperative recovery.

Concomitant sacroiliac joint abnormalities in patients with femoroacetabular impingement

PURPOSE

Despite the increasing understanding of femoroacetabular impingement (FAI), the impact of specific patient characteristics, including inflammatory pathologies like axial spondyloarthritis (axSpA), on its pathophysiology and clinical outcomes following treatment remains inadequately defined. Therefore, the purpose of this scoping review was to evaluate the relationship between FAI and sacroiliac (SI) joint abnormalities and FAI and axSpA.

METHODS

The study was conducted following the framework established by Arksey and O'Malley and Levac et al., adhering to the PRISMA scoping review extension checklist. A systematic search was performed across MEDLINE, EMBASE, and Cochrane Library databases for articles published until August 2024. A total of 120 articles were screened and eight finally met the inclusion criteria.

RESULTS

The review analysed data from the eight retrospective studies with a total of 1,723 patients. We found that the prevalence of SI joint abnormalities in patients with FAI can be as high as 25-28%. Furthermore, the prevalence of FAI morphology in patients with axial spondyloarthritis can be as high as 20-37%. Finally, patients undergoing hip arthroscopy for FAI with axSpA and/or SI joint abnormalities have lower postoperative outcome scores reported in comparison with those patients who do not have these comorbidities.

CONCLUSION

Over a quarter of patients with FAI can have concomitant radiographic SI joint abnormalities. We cannot overemphasise the importance of assessing the spine, specifically the SI joint, and ruling out symptoms emanating from the SI joint in all patients with FAI. There is clearly a knowledge gap in understanding the underlying pathophysiology linking FAI and axSpA. We require further research to elucidate the underlying mechanisms of this relationship, standardise evaluation methods, and explore long-term outcomes in this cohort of patients.

Doctor when can I drive? A systematic review and meta-analysis of brake reaction time in patients returning to driving after hip arthroscopy for femoroacetabular impingement (FAI)

BACKGROUND

A common question from patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) is when they may return to driving.

PURPOSE

We aimed to perform a formal systematic review and meta-analysis to address this issue.

METHODS

A systematic review and meta-analysis followed PRISMA guidelines. Databases searched included OVID, EMBASE, and COCHRANE through July 2024 for articles with keywords and MeSH terms like "Hip arthroscopy," "Femoroacetabular Impingement," "total brake response time," and "reaction time" related to driving. Titles and full articles were reviewed for quality and relevance. Statistical analysis was done using Review Manager Version 5.4.A total of 39 articles were reviewed, with 5 meeting inclusion criteria. All selected articles used brake reaction time (BRT) as an outcome measure. A meta-analysis compared pre- and postoperative BRT values. Data were analysed for the right and left hips combined, followed by a subgroup analysis by laterality. BRT values were divided into preoperative and 2, 4, 6, and 8 weeks postoperative periods.

RESULTS

The studies assessed 160 patients, with 142 undergoing hip arthroscopy for FAI. The mean age was 32.75 ± 9.4 years, with a male-to-female ratio of 73:69. The right hip was affected in 68% of patients. Preoperative BRT ranged from 566 to 1960 milliseconds, while postoperative BRT ranged from 567 to 1860 milliseconds between week 2 and week 12.

CONCLUSIONS

BRTs returned to baseline or control values and continued to improve 4 weeks post-surgery for FAI. It is safe to recommend a return to driving at 4 weeks after hip arthroscopy for FAI.

Arthroscopic Management of Femoroacetabular Impingement: Current Concepts

Background: Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction, especially in young and active individuals, and it may require surgical management for associated labral tears and cartilage damage. The management of FAI has advanced radically over the last few years, and hip arthroscopy has gained a leading role. However, despite the increasing number of published research and technological advancements, a comprehensive systematic review summarising current evidence is still missing. Methods: All the clinical studies investigating the arthroscopic management of FAI were accessed. Only studies with a minimum of six months of follow-up were considered. The 2020 PRISMA guidelines were followed. In December 2024, PubMed, Web of Science, and Embase were accessed without time constraints. Results: The present systematic review included 258 clinical investigations (57,803 patients). The mean length of follow-up was 34.2 ± 22.7 months. The mean age was 34.7 ± 5.3, and the mean BMI was 25.1 ± 2.0 kg/m2. Conclusions: The present systematic review updates current evidence on patients who have undergone arthroscopic surgery for FAI, updating and discussing current progress in managing labral injuries and patient selection, emphasising outcomes and pitfalls. Progress in surgery and improvement in eligibility criteria, as well as current controversies and prospects, were also discussed.

The Alpha Angle

➢ The alpha angle was originally defined on magnetic resonance imaging (MRI) scans, using a plane, parallel to the axis of the femoral neck. However, much of the literature on the alpha angle has used radiographs or other imaging modalities to quantify the alpha angle.➢ The measurement of the alpha angle can be unreliable, particularly on radiographs and ultrasound.➢ If radiographs are used to measure the alpha angle, the circle of best-fit method should be used on multiple different views to capture various locations of the cam lesion, and "eyeballing" or estimating the alpha angle should be avoided.➢ The cam lesion is a dynamic and 3-dimensional (3D) problem and is unlikely to be adequately defined or captured by a single angle.➢ Modern technology, including readily available 3D imaging modalities, as well as intraoperative and dynamic imaging options, provides novel, and potentially more clinically relevant, ways to quantify the alpha angle.

Return to Sport Following Arthroscopic Management of Femoroacetabular Impingement: A Systematic Review

Background: Femoroacetabular impingement (FAI) is common. The present systematic review updates the current evidence on return to sport (RTS) in patients who have undergone arthroscopic surgery for FAI in any of its variants (CAM, pincer, or both). Methods: The outcomes of interest were sports-related patient-reported outcome measures (PROMs) and the level and time to RTS. All available clinical studies concerning the RTS following arthroscopic management of FAI were considered. In July 2024, the following databases were accessed following the PRISMA guidelines: Embase, Web of Science, and PubMed. Only studies with a minimum of six months of follow-up were eligible. Results: From 1245 initially identified articles, 43 studies (4103 patients) met the inclusion criteria, in which 32.1% (1317 of 4103 patients) were women. The mean length of follow-up was 33.7 ± 15.8 months. The mean age was 28.1 ± 7.2 years, the mean BMI was 24.7 ± 6.4 kg/m2, and 79.6% ± 27.8% of patients returned to sport at the same or higher level at a mean of 14.3 ± 9.6 months. The mean time away from sports was 8.0 ± 3.3 months. Conclusion: Arthroscopic management for FAI leads to a high rate of RTS, with approximately 80% of patients returning to their preinjury level. Future research should focus on standardised definitions of RTS, sport-specific rehabilitation protocols, and the influence of deformity and procedures on RTS.

No Differences in Clinical Outcomes Between Hip Arthroscopy With Versus Without Capsular Closure in Patients With Cam- or Mixed-Type Femoroacetabular Impingement: A Randomized Controlled Trial

PURPOSE

To compare 2-year clinical outcomes of primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in patients with cam- or mixed-type femoroacetabular impingement (FAI).

METHODS

Patients with cam- or mixed-type FAI undergoing primary hip arthroscopy with interportal capsulotomy were prospectively enrolled in this randomized controlled trial (RCT) and allocated into either capsular closure or no capsular closure groups. Patients were blinded to group allocation. Clinical outcomes were assessed preoperatively and at 2-year follow-up using the 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and 6 subsections of the Copenhagen Hip and Groin Outcome Score (HAGOS). Complications and reoperations were noted.

RESULTS

Eighty-four patients (100 hips) were enrolled, 49 hips in the capsular closure group and 51 in the no capsular closure group, with no significant differences in age (28.5 ± 7.5 vs 30.4 ± 8.4, P = .261), body mass index (23.5 ± 3.0 vs 23.4 ± 1.9, P = .665), and sex distribution (female: 10.2% vs 13.7%, P = .760). Four patients were lost to follow-up (2.0% vs 5.9%, P = .618) and 6 had reoperations (6.1% vs 5.9%, P = 1.000), which left 45 hips per group for clinical assessment. There were no significant differences between groups in the net change of iHOT-12 (28.3 ± 19.6 vs 32.5 ± 22.7, P = .388), mHHS (7.6 ± 13.1 vs 7.5 ± 10.2, P = .954), and subsections of HAGOS (P > .05). Complication rates were also similar between groups (P > .05).

CONCLUSIONS

The present RCT compared primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in a male-dominated, non-dysplastic, non-arthritic cohort with cam- or mixed-type FAI and found no significant differences in patient-reported clinical outcomes, complication rates, or reoperation rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Editorial Commentary: Long-Term Follow-Up After Endoscopic Gluteal Repair Plus Hip Arthroscopy Shows Durable Results Using Validated Patient-Reported Outcome Scores That Largely Exceed the Minimal Clinically Important Difference and Patient Acceptable Symptom State

Gluteus medius and minimus tendon pathology is a common cause of lateral hip pain. In patients who are dissatisfied with their hip condition following nonsurgical treatment, gluteal repair has demonstrated excellent short-, mid-, and, now recently, long-term subjective patient-reported and objective clinician-measured outcomes. In patients with peritrochanteric hip pain, the proportion of their overall hip pain may be influenced by the hip joint due to conditions like femoroacetabular impingement syndrome, acetabular dysplasia, labral tears, and arthritis. Thus, surgical decision-making must include consideration of also addressing the joint at the same time as the gluteal repair. This is sometimes challenging due to the high frequency of observing labral injuries and cam/pincer/dysplasia morphology in patients without symptoms due to the "radiographic abnormalities." Labral pathology is also more prevalent in older patients, who happen to also be those individuals with symptomatic gluteal tendon pain. Both open and endoscopic approaches to the gluteal tendons have advantages and disadvantages without significant outcomes differences in the short- or mid-term. Long-term clinical follow-up of patients treated with endoscopic gluteal repair with or without concomitant hip arthroscopy should be included in large national and international prospective registries using validated, reliable, and responsive patient-reported outcome scores, with clinical importance assessed using the minimal clinically important difference, patient acceptable symptom state, substantial clinical benefit, and maximal outcome improvement.

Feasibility of embedding orthopaedic clinical trials into national registries: a pilot quality improvement study for the UK Non-Arthroplasty Hip Registry (UK-NAHR)

The integration of 'Registry-based Randomised Control Trials' (RRCT) into national registries has the potential to catalyse prospective research, enhancing the evidence base for practice. The aim of this study was to assess the feasibility of embedding a trial within the UK Non-Arthroplasty Hip Registry. This was a national observational, multi-centre study. Six pilot sites within the UK were provided with additional support for data collection. We compared the ability of these pilot sites to collect data with the ability of centres where no additional support was provided. We collected information on patient compliance, efficacy and adverse events of drugs routinely used after hip preserving surgery. The primary outcome measure was compliance with data collection in these centres at 30 and 90 days after surgery. Our intention was to assess the feasibility of, and factors influencing, the capturing data for interventional registry trials in the future. Two hundred and twenty-eight patients were enrolled in the Non-Arthroplasty Hip Registry during the study period (114 within pilot centres and 114 in non-pilot centres). Pilot centres had a mean follow-up compliance of 79% (30 days) and 69.4% (90 days) in contrast to 55% (30 days) and 47% (90 days) in the non-pilot centres (P = 0.009/P = 0.0058). The study revealed that supplementary administrative support resulted in improved compliance. However, deficient administration systems negatively impacted follow-up, and surgeon motivation emerged as a crucial determinant in ensuring robust follow-up. The lessons learned from this feasibility trial could be useful for any national registry embedding prospective, registry-based trials.

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study

PURPOSE

To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater.

METHODS

An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%.

RESULTS

Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration.

CONCLUSIONS

There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy.

LEVEL OF EVIDENCE

Level V, expert opinion.

PREHAB FAI- Prehabilitation for patients undergoing arthroscopic hip surgery for Femoroacetabular Impingement Syndrome -Protocol for an assessor blinded randomised controlled feasibility study

BACKGROUND

The past decade has seen an exponential growth of minimally invasive surgical procedures. Procedures such as hip arthroscopy have rapidly grown and become the standard of care for patients with Femoroacetabular Impingement Syndrome (FAIS). Although, the results of such procedures are encouraging, a large proportion of patients do not achieve optimal outcomes due to chronicity and deconditioning as a result of delay in diagnosis and increased waiting times amongst other factors. In a recent systematic review and meta-analysis of randomised control trials, moderate certainty evidence supported prehabilitation over standard care in optimising several domains including muscle strength, pain and health related quality of life in patients undergoing orthopaedic surgical interventions. However, the role of prehabilitation in patients with FAI syndrome undergoing hip arthroscopy has received little attention.

AIM

To evaluate the feasibility, suitability, acceptability and safety of a prehabilitation programme for FAI to inform a future definitive randomised control trial to assess effectiveness.

METHODS

A systematically developed prehabilitation intervention based on a literature review and international consensus will be utilised in this study. A mixed methodology encompassing a two-arm randomised parallel study alongside an embedded qualitative component will be used to answer the study objectives. Patients will be recruited from a tertiary referral NHS centre for young adult hip pathology in the UK. Patient reported outcomes such as iHOT-12, Brief Pain Inventory Scale (Short form), Hospital Anxiety and Depression Scale and Patient Global Impression of Change score will be obtained alongside objective measurements such as Muscle Strength and Star Excursion Balance Test at various time points. Outcome measures will be obtained at baseline (prior to prehabilitation intervention), after prehabilitation before surgery, and at 6 weeks+/- 4 weeks and 6 months +/- 4 weeks (planned primary endpoint for definitive RCT) postoperatively when participants attend the research site for clinical care and remotely at 12 months +/- 4 weeks postoperatively. Mean change and 95% CI, and effect size of outcome measures will be used to determine the sample size for a future RCT. For the qualitative component, in depth face-to-face semi-structured interviews with physiotherapists and focus groups with participants will be conducted to assess the feasibility, suitability, and acceptability of the prehabilitation intervention using a predetermined success criteria. All qualitative data will be recorded, transcribed verbatim and thematically analysed.

DISCUSSION

This study will be first of its kind to evaluate a systematically developed prehabilitation intervention for patients with FAIS undergoing hip arthroscopy. This study will provide important preliminary data to inform feasibility of a definitive RCT in the future to evaluate effectiveness of a prehabilitation intervention.

TRIAL REGISTRATION

ISRCTN 15371248, 09/03/2023.

TRIAL PROTOCOL

Version 2.3, 26th June 2023.

Editorial Commentary: Artificial Intelligence Analysis of Biomedical, Large, Clinical Registry Data Using Machine Learning Requires Tens of Thousands of Subjects and a Focus on Substantial Clinical Benefit: Minimal Clinically Important Difference Is too Low a Bar

As the field of arthroscopic hip preservation surgery grows, large high-quality registries represent a foundational study design for establishing whether hip arthroscopy is effective for patients with femoroacetabular impingement syndrome (FAIS). Original research publications from experienced high-volume surgeons tell us "Can it work". A registry tells us "Does it work?". The ability of preservation to truly preserve the joint, delay the arthritis process, and reduce the risk of arthroplasty requires long-term follow-up. A geographic registry can follow this. The registry represents the "real world", a heterogeneous set of variables pertaining to the doctor, patient, intervention, and outcome. The vast array of factors that can be analyzed before, during, and after surgery makes machine learning an ideal technique for analysis of large quantities of data. A global hip preservation surgery registry is a desirable and achievable goal. In order to optimally predict outcome of hip arthroscopy, given the known large number of patient- and hip-specific factors that influence outcomes, a deep learning model with tens of thousands of subjects for this medium-scale task would be needed. Measures of clinical relevance need to include more than just MCID (minimal clinically important difference), which is the lowest bar minimal threshold. Patient expectations often far exceed MCID-requiring other metrics like SCB (substantial clinical benefit), PASS (patient acceptable symptom state), and MOI (maximal outcome improvement). Registries should include validated, reliable, and responsive patient-reported outcome scores (e.g., International Hip Outcome Tool [iHOT-12]) with measures of clinical relevance and expectations assessed routinely. The United Kingdom's NAHR (Non-Arthroplasty Hip Registry) and Denmark's DHAR (Danish Hip Arthroscopy Registry) are the two largest geography-based registries in current hip preservation research both with 11 years of patient enrollment.

Current concepts in the diagnosis and management of Os Acetabuli

PURPOSE

The aim of this review is to appraise the current evidence on the epidemiology, pathophysiology, diagnosis and management of os acetabuli.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute guidelines. A systematic search was performed on Medline (PubMed), Embase and Cochrane Library. Inclusion criteria comprised observational and interventional studies and review articles published in the English language that focused on patients with os acetabuli according to the PRISMA extension of scoping reviews checklist using the terms 'Os Acetabuli' or 'os acetabula' or 'acetabular ossicles'. A narrative synthesis of results was undertaken, and the included articles were divided into (i) definition, (ii) aetiology, (iii) diagnosis and imaging and (iv) management of os acetabuli.

RESULTS

107 articles were screened, with 22 meeting the eligibility criteria. A total of 8836 patients were considered, of which 604 had os acetabuli. The mean age was 32.8 years. The prevalence of os acetabuli ranged from 3.4 to 7.7%, with a higher prevalence in males compared to females. True os acetabuli was defined as an unfused secondary ossification centre along the acetabular rim. The aetiology of os acetabuli is thought to be secondary to acetabular dysplasia and/or femoroacetabular impingement. Standard of care for management of symptomatic os acetabuli is considered to be arthroscopic excision unless the excision results in acetabular undercoverage and/or instability, in which case, fixation is recommended.

CONCLUSIONS

Successful management of os acetabuli depends on understanding the pathology and treating the underlying cause rather than treating the os acetabuli in isolation. Future work needs to focus on establishing clear diagnostic criteria, consensus on definition and an evidence-based treatment algorithm.

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Methods

A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected.

Results

A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015).

Conclusion

There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.