Low Rates of 5-Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients

Social Determinants of Health Disparities Increase 5-Year Revision Rates but Not Postoperative Complications After Primary Hip Arthroscopy

PURPOSE

To investigate the impact of social determinants of health (SDOH) disparities on 30-day emergency department (ED) visits, 90-day postoperative complications, and 5-year secondary surgery rates after primary hip arthroscopy using a large national database.

METHODS

A national administrative claims database was used to identify patients who underwent primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2022. Queries were performed to identify patients who experienced any SDOH disparities, including economic, educational, environmental, or social disparities; those experiencing SDOH disparities within 1 year prior to primary hip arthroscopy were matched 1:1 by age, sex, Elixhauser Comorbidity Index score, diabetes, obesity, and tobacco use to patients not experiencing any lifetime SDOH disparities. The odds of 90-day complications and 30-day ED visits were compared using multivariable logistic regression. Rates of 5-year revision hip arthroscopy and of any secondary surgery (revision hip arthroscopy or total hip arthroplasty) were compared by Kaplan-Meier analysis.

RESULTS

A total of 3,383 primary hip arthroscopy patients who experienced SDOH disparities were matched 1:1 to a control cohort of 3,383 patients who did not experience SDOH disparities (age of 41.0 years and 79.6% female sex in both cohorts). The odds of adverse events after arthroscopy were low and did not differ between the SDOH cohort (1.51%) and no-SDOH cohort (1.57%, P = .09). Additionally, there was no difference in the odds of 30-day ED visits between the SDOH cohort (5.65%) and no-SDOH cohort (4.79%, P = .10). The rate of 5-year revision hip arthroscopy was significantly greater among patients experiencing SDOH disparities (5.4% vs 4.1%, P = .02); however, there was no difference in the rate of any secondary surgery between cohorts (11.8% vs 10.4%, P = .10).

CONCLUSIONS

Patients experiencing SDOH disparities had similar odds of postoperative complications and ED visits after primary hip arthroscopy but greater rates of 5-year revision hip arthroscopy compared with a matched-control cohort of patients not experiencing SDOH disparities.

LEVEL OF EVIDENCE

Level III, retrospective case-control study.

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.

Socioeconomic Factors Including Patient Income, Education Level, and Health Insurance Influence Postoperative Secondary Surgery and Hospitalization Rates Following Hip Arthroscopy

PURPOSE

To evaluate a large cross-sectional sample of patients utilizing administrative database records and analyze the effects of income, insurance type, and education level on outcomes after hip arthroscopy, including 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations.

METHODS

Current Procedural Terminology codes were used to query the PearlDiver Mariner database from October 2015 to January 2020 for patients undergoing hip arthroscopy with a minimum 2-year follow-up. Patients were categorized by mean family income in their zip code of residence (MFIR), health insurance type, and educational attainment in their zip code of residence (EAR). Two-year revision arthroscopy, conversion to THA, and 90-day hospital readmissions or emergency department (ED) visits were analyzed along socioeconomic strata.

RESULTS

Multivariate analysis of 33,326 patients revealed that patients with MFIR between $30,000 and $70,000 had lower odds of 2-year revision arthroscopy (odds ratio [OR], 0.63; P < .001), THA conversion (OR, 0.76; P = .050), and 90-day readmission (OR, 0.53; P = .007) compared to MFIR >$100,000. Compared to patients with commercial insurance, patients with Medicare had lower odds of revision arthroscopy (OR, 0.60; P = .035) and THA conversion (OR, 0.46, P < .001) but greater odds of 90-day readmission (OR, 1.74; P = .007). Patients with Medicaid had higher odds of 90-day ED visits (OR, 1.84; P < .001). Patients with low EAR had higher odds of revision arthroscopy (OR, 1.42; P = .005) and THA conversion (OR, 1.58; P = .002) compared to those with high EAR.

CONCLUSIONS

Following hip arthroscopy, patients residing in areas with lower mean family income were less likely to undergo reoperations and readmissions. Medicare patients showed lower reoperation but higher readmission odds, while Medicaid patients showed higher odds of ED visits. Additionally, higher educational attainment in the zip code of residence is protective against future reoperation.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Total Shoulder Arthroplasty in Patients With Hemophilia A: Greater Odds of Postoperative Bleeding and Thromboembolic Events but No Difference in 5-year Implant Survival

BACKGROUND

Patients with hemophilia A can develop joint hemarthroses, degenerative changes, and eventually undergo total shoulder arthroplasty (TSA). Few data exist concerning complications and prosthesis survival after TSA in this population.

QUESTIONS/PURPOSES

(1) Is hemophilia A associated with more bleeding and thromboembolic adverse events after TSA relative to matched controls? (2) Is 5-year TSA prosthesis survival reduced in patients with hemophilia A compared with matched controls?

METHODS

The 2010 to 2022 PearlDiver M161 database was used to identify patients who underwent primary anatomic or reverse TSA. Given that the X-linked recessive condition hemophilia A presents nearly exclusively in males, male patients with hemophilia A who underwent TSA were matched 1:10 with male patients without hemophilia who underwent TSA based on age and Elixhauser comorbidity index (ECI). This yielded 73 patients with hemophilia A who underwent TSA who were matched 1:10 with 729 patients without hemophilia. Ninety-day adverse events were compared with multivariable analysis. Revision within 5 years was assessed using Kaplan-Meier analysis.

RESULTS

Compared with the control cohort, patients with hemophilia had greater odds of bleeding issues (hematoma, OR 6.8 [95% CI 3.0 to 15.3]; p < 0.001; anemia, OR 2.5 [95% CI 1.5 to 4.2]; p < 0.001, transfusion, OR 5.0 [95% CI 2.4 to 10.3]; p < 0.001), venous thromboembolic events (VTE) (OR 1.9 [95% CI 1.1 to 3.1]; p = 0.01), and prosthetic loosening (OR 3.5 [95% CI 1.4 to 8.0]; p = 0.004). Based on available data, 5-year implant survival was not different in patients with hemophilia (97.3% [95% CI 93.6% to 100.0%]) relative to matched controls (95.2% [95% CI 93.4% to 97.2%]; p = 0.60).

CONCLUSION

The elevated risks of both 90-day bleeding complications (hematoma, anemia, and transfusion) and VTE (DVT and PE) in patients with hemophilia emphasize the special challenges of carefully balancing factor replacement and VTE prophylaxis pre-, intra-, and postoperatively on an individual patient basis with careful hematologist coordination. Further study on Factor VIII levels and targets as well as tranexamic acid and VTE prophylaxis in this population is necessary to provide further guidance. Furthermore, 5-year implant survival was not different between patients with hemophilia and matched controls (patients without hemophilia) based on available data, suggesting that TSA survivorship remains durable and may be offered to patients in this population as indicated.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Medicare and Medicaid patients undergoing total joint arthroplasty have more complications and healthcare utilization than privately insured patients

Aims & objectives

This study characterized the independent association between insurance type and healthcare outcomes in patients undergoing total joint arthroplasty (TJA).

Materials &methods

National data identified patients who underwent total hip, knee, shoulder, elbow, ankle or wrist joint arthroplasty surgery from 2012 to 2020 for osteoarthritis. Medicaid, Medicare≥65 years old, Medicare<65 years old, and uninsured patients were matched to privately insured patients based on age, sex, and comorbidities. Multivariable analysis, controlled for various characteristics, was conducted to quantify various outcome measures by payer status.

Results

Medicaid patients had greater odds of cardiac, genitourinary, hematoma/hemorrhage/seroma, respiratory, and wound dehiscence complications than privately insured (odds ratio [OR]: 1.5, 1.2, 1.6, 1.3, 1.5, respectively; p < 0.01). Medicare patients ≥65 years old had greater odds of cardiac and wound dehiscence complications but fewer central nervous system and genitourinary complications and post-operative infections than privately insured (OR:1.2, 1.2, 0.3, 0.8, 0.7, respectively; p < 0.01). Medicare<65 years old patients had greater odds of cardiac, gastrointestinal, genitourinary, hematoma/hemorrhage/seroma, post-operative anemia, respiratory, and wound dehiscence complications than privately insured (OR: 1.2, 1.4, 1.2, 1.4, 1.2, 1.7, 1.6, respectively; p < 0.01). Medicare≥65, Medicare<65, and Medicaid patients had $2,243, $3,849, and $1170 more total charges, respectively (p < 0.01).

Conclusion

Despite Medicaid expansion through the 2014 Affordable Care Act, marked disparities in complications after TJA between individuals with and without private insurance still exist. Medicare<65 and Medicaid cohorts demonstrated higher complication rates than private payers, possibly attributable to barriers in healthcare such as patient education, access to healthcare, and social determinants of health.

Female Patients Undergoing Latarjet Surgery Show Similar 2-Year Secondary Surgery Rates but Greater Risk of Emergency Department Visits Compared With a Matched Cohort of Male Patients

PURPOSE

To evaluate sex-based differences in 30-day postoperative emergency department (ED) visits, 90-day complication rates, and 2-year secondary surgery rates after the Latarjet procedure for the treatment of recurrent shoulder instability.

METHODS

A national administrative claims database was used to identify patients with International Classification of Diseases, Tenth Revision (ICD-10) diagnosis codes for shoulder subluxation or dislocation on the day of first-time stabilization with the Latarjet technique between 2015 and 2021. Male patients were matched 4:1 to female patients based on age, Elixhauser Comorbidity Index (ECI) score, and body mass index class. Rates of 30-day ED visits and 90-day complications were compared between cohorts, and risk factors for ED visits were identified by multivariate regression. The incidence of secondary surgery within 2 years was compared by Kaplan-Meier analysis.

RESULTS

Prior to matching, 1,059 male and 360 female patients met the inclusion and exclusion criteria. Subsequent 4:1 (male-to-female) matching controlling for age, ECI score, and body mass index yielded 694 male and 185 female patients who underwent the Latarjet procedure. The overall incidence of 30-day ED visits was 9.3%, with an incidence of 8.2% for male patients and 13.5% for female patients. On the basis of multivariate logistic regression, these 30-day ED visits were associated with female sex (odds ratio, 1.79; P = .029) and incrementally higher ECI scores; relative to an ECI score of 0, ECI scores of 1 to 2, 3 to 4, and 5 or greater were associated with odds ratios of 5.31 (P = .006), 8.12 (P < .001), and 12.84 (P < .001), respectively. Ninety-day complications occurred in 1.5% of the total cohort, and the incidence was not statistically different between sexes. Overall, 2-year secondary surgery rates were similar between male and female patients (5.1% and 6.7%, respectively; P = .4).

CONCLUSIONS

Female patients undergoing the Latarjet procedure for recurrent shoulder instability showed similar 90-day complication and 2-year secondary surgery rates to a matched cohort of male patients. Female sex, along with ECI score, however, was associated with a greater rate of 30-day ED visits.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

A Multicenter Analysis of 3 Decades of Hip Arthroscopy: Evolving Techniques and Growing Patient Volumes From 1988 to 2022

Background

The number of hip arthroscopies performed in the United States has grown significantly over the past several decades, with evolving indications and emerging techniques.

Purposes

To (1) examine the evolution of hip arthroscopy at 3 tertiary referral centers between 1988 and 2022 and (2) quantify trends in patient demographics and procedures performed.

Study Design

Case series; Level of evidence, 4.

Methods

A retrospective analysis was performed of all patients undergoing hip arthroscopy at 3 academic centers between 1988 and 2022. Demographic data were collected using standardized forms and operative notes, and intraoperative images were manually reviewed for each patient to determine the specific procedures performed at the time of the hip arthroscopy. Surgical procedures were plotted over time to evaluate trends. Patients were divided into 3 time periods for comparison: early hip arthroscopy from 1988 to 2008, 2009 (the time of the first labral repair in our cohort) to 2015, and 2016 to 2022.

Results

A total of 3000 patients (age, 35.7 ± 13.8 years; age range, 10-89 years; female sex, 2109 (70.3%); body mass index, 27.4 ± 6.3 kg/m2) underwent arthroscopic hip procedures between 1988 and 2022. The mean number of cases increased from a mean of 3.2 per year in 1988-2008 to 285.9 per year in 2016-2022 (P < .001). Labral treatment at the time of primary hip arthroscopy evolved from 100% debridement and 0% repair in 1988-2008 to 5.0% debridement, 94.0% repair, and 1.0% labral reconstruction in 2016-2022 (P < .001). Cam resection increased from 4.1% in 1988-2008 to 86.9% in 2016-2022 (P < .001). By 2022, 45 out of 325 cases (13.8%) were revisions. The rate of capsular repair at the time of primary hip arthroscopy increased from 0.0% in 1988-2008 up to 81.0% in 2016-2022.

Conclusion

There has been a significant growth of hip arthroscopy volumes as well as a significant transition from use as a tool for diagnosis and labral debridement to procedures restoring native anatomy including labral repair, cam resection, capsular repair, periacetabular osteotomy, and gluteal repair.

The Use of Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia Is Increasing and Has Low Complication Rates

Purpose

To analyze the annual use of hip arthroscopy (HA) and Bernese periacetabular osteotomy (PAO) for the treatment of hip dysplasia (HD), as well as postoperative outcomes, including ipsilateral reoperations.

Methods

International Classification of Diseases, Ninth and Tenth Revision, codes were used to query the PearlDiver Mariner database from January 2010 through January 2022 to identify patients aged 10 to 59 years who had a presenting diagnosis of HD and subsequently underwent (1) HA; (2) PAO; or (3) combined HA and PAO (HA-PAO, defined as PAO on the same day or within 28 days after HA). We analyzed annual rates for each treatment, as well as rates of postoperative emergency visits, readmissions, and 5-year ipsilateral secondary operations (determined via Kaplan-Meier analysis).

Results

There were 32,068 patients who underwent surgical treatment of HD. For HA, PAO, and HA-PAO, there were 29,700, 2,083, and 285 patients, respectively. All operations had the greatest percent-increase from 2015 to 2016. HA and HA-PAO peaked in 2021, whereas PAO peaked in 2019. For HA, PAO, and HA-PAO, most cases were performed in female patients and patients aged 30 to 49 years, 10 to 19 years, and 10 to 29 years, respectively. The 5-year incidence of ipsilateral secondary operations, which include revision HA, PAO, or conversion to total hip arthroplasty, was 9.2% (95% confidence interval 8.6%-9.8%) in the HA group and 6.5% (95% confidence interval 4.1%-8.8%) in the PAO group. Combining HA with PAO resulted in so few secondary operations that Kaplan-Meier analysis was infeasible. The PAO cohort had the greatest 30-day emergency visit and 90-day readmission rates, with infection as the most common cause for readmission.

Conclusions

HA is more frequently performed than PAO for hip dysplasia. HA-PAO is increasing at the greatest rate, demonstrating fewer complications and reoperations.

Level of Evidence

Level III, retrospective comparative trial.

Hip Arthroscopy Followed by 6-Month Rehabilitation Leads to Improved Periarticular Muscle Strength, Except for Abductors and External Rotators

Purpose

To evaluate the variations in hip muscles strength following arthroscopy and 6-month rehabilitation in patients treated for femoroacetabular impingement (FAI).

Methods

A retrospective analysis was carried out on a series of patients who were arthroscopically treated for FAI at La Tour Hospital between 2020 and 2022. Bilateral isometric strengths of 8 hip-related muscles (abductors, adductors, hamstrings, quadriceps, extensors, flexors, internal and external rotators) were assessed using a handheld dynamometer before surgery and postoperatively after 6 months of rehabilitation in terms of relative strength changes between time points.

Results

A total of 29 patients (aged 26.9 ± 7.1 years, 86% of women) were included. Except for the abductors, which remained of comparable strength than before surgery, a statistically significant (P < .05) increase in hip muscle strength on the operated side could be noted at 6 postoperative months for hamstrings (9% ± 17%, P = .041), quadriceps (11% ± 27%, P = .045), extensors (17% ± 32%, P = .006), flexors (17% ± 29%, P = .003), adductors (18% ± 23%, P < .001), and internal rotators (32% ± 36%, P < .001). The proportion of patients who reached a strength level above their preoperative status ranged from 62% (quadriceps) to 86% (adductors and flexors), depending on the muscle studied. The external rotators were the only muscles that remained significantly weakened at 6 months on both operated (-13% ± 26%, P = .002) and nonoperated (-17% ± 25%, P < .001) sides, with a decrease beyond 15% in almost half of the patients (45% and 48%, respectively).

Conclusions

Arthroscopic treatment followed by 6-month rehabilitation granted to most FAI patients a higher strength level for several hip muscles, except for abductors and external rotators, which remained comparable and weakened, respectively.

Level of Evidence

Level IV, therapeutic case series.

Defining Thresholds and Predictors for Achieving the Patient Acceptable Symptom State for Patient-Reported Outcome Measures After Revision Hip Arthroscopy

BACKGROUND

The Patient Acceptable Symptom State (PASS) after primary hip arthroscopy has been determined; nonetheless, the PASS still needs to be defined for revision hip arthroscopy.

PURPOSE

To define minimum 2-year follow-up PASS thresholds for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and International Hip Outcome Tool-12 (iHOT-12) after revision hip arthroscopy, and to identify predictors of achieving the PASS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included if they had baseline and minimum 2-year follow-up scores for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12. PASS was calculated using the anchor-based method. Receiver operating characteristic curve analysis was used to determine the thresholds for the PASS. A multivariate logistic regression was used to identify predictors for achieving the PASS.

RESULTS

A total of 318 patients who underwent revision hip arthroscopy met the inclusion criteria. Of those patients, 292 (91.8%) had baseline and minimum 2-year follow-up. Of this group, 68 patients (72.1% female and 27.9% male; mean age, 32.9 years) answered the PASS anchor question. Achievement PASS rates were 58.8%, 41.2%, 52.9%, 60.3%, and 52.9% for the mHHS, NAHS, HOS-SSS, VAS, and iHOT-12, respectively. The area under the curve (AUC) values for the PASS for mHHS, NAHS, HOS-SSS, VAS, and iHOT-12 were 0.912, 0.888, 0.857, 0.903, and 0.871, respectively, indicating excellent discrimination. The PASS for the mHHS was 76 (sensitivity, 0.809; specificity, 0.905), for the NAHS was 86.3 (sensitivity, 0.660; specificity, 1), for the HOS-SSS was 64.3 (sensitivity, 0.745; specificity, 0.905), for the VAS was 3 (sensitivity, 0.830; specificity, 0.905), and for the iHOT-12 was 64.3 (sensitivity, 0.745; specificity, 0.905). Body mass index (BMI) was identified as a significant predictor of achieving PASS for the NAHS (OR, 0.967; 95% CI, 0.940-0.996; P = .027), as patients with a BMI ≤25.4 had 1.03 times higher odds ratio of achieving PASS for the NAHS.

CONCLUSION

After revision hip arthroscopy, the minimum 2-year follow-up PASS thresholds for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12 were 76, 86.3, 64.3, 3, and 64.3, respectively. The odds ratio of achieving PASS for the NAHS was 1.03 times higher for patients with a BMI ≤25.4.

Editorial Commentary: Rates of 5-Year Secondary Surgery After Hip Arthroscopy May Be Higher Than Reported: The Highs and Lows of the Administrative Database Study

Administrative claims databases have great power for clinical research, especially when used to evaluate trends from large cohorts. However, it should be noted that in these types of studies, patients in a database are treated at different time points, so some patients do not reach long-term follow-up by the end of the study period. Thus, such analyses require more stringent inclusion and exclusion criteria, which may significantly reduce the size of the included cohort. Recent research using the PearlDiver database has reported that the 5-year secondary surgery rate after hip arthroscopy is 4.9%. However, our research using the PearlDiver Mariner data set showed a 2-year reoperation rate after hip arthroscopy of 15%, and although most secondary surgical procedures occur within the first 2 years after hip arthroscopy, the 5-year reoperation rate may be higher. Readers should remain alert to the limitations of large database analyses.