Capsular Repair is Associated with Lower Revision Rates Yet Similar Clinical Outcomes and Arthroplasty Conversion 5-Years after Hip Arthroscopy: A Systematic Review

The THA-10 Score for Predicting Conversion to Total Hip Arthroplasty After Contemporary Hip Arthroscopy for Femoroacetabular Impingement Syndrome at a Minimum 10-Year Follow-up

BACKGROUND

Previous studies have identified predictors of total hip arthroplasty (THA) conversion after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) at short- to midterm follow-up, yet no studies to the authors' knowledge have established a scoring system for predicting THA conversion at a minimum 10-year follow-up.

PURPOSE

To create a scoring system to predict 10-year THA conversion after contemporary HA for FAIS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected from patients undergoing primary contemporary HA for FAIS, including labral repair, osteoplasty of FAIS deformity, and capsular repair, between January 2012 and October 2013, with a minimum 10-year follow-up. Patients who underwent THA conversion were compared with patients who achieved 10-year THA-free survivorship. Significant predictors of THA conversion were identified, and predictor weights were assigned to create the THA-10 score. The score was applied to the cohort, and its clinical utility was evaluated. The threshold score with the greatest sensitivity and specificity for predicting 10-year THA conversion was identified.

RESULTS

In total, 280 patients were included; 21 (7.5%) underwent THA conversion by the 10-year follow-up. Patients who underwent THA conversion were of older age (45.4 ± 11.3 vs 33.2 ± 12.1 years; P < .001), had a greater body mass index (28.0 ± 5.2 vs 24.8 ± 4.7 kg/m2; P = .011), and had a greater prevalence of Tönnis grade 1 osteoarthritis (42.9% vs 14.3%; P = .003) and high-grade acetabular (61.9% vs 12.7%; P < .001) and femoral head (33.3% vs 7.3%; P < .001) chondral defects compared with THA-free survivors. After variable weighting, the THA-10 score was established as 1 point for body mass index ≥25 kg/m2, 1 point for Tönnis grade 1, 2 points for age ≥47 years, and 3 points for high-grade defects of the acetabulum or femoral head. The THA-10 score was found to have clinically significant diagnostic value with an area under the receiver operating characteristic curve of 0.823. Patients scoring ≥4 points were 13.2 times more likely to undergo THA conversion (95% CI, 5.0-35.1; P < .001).

CONCLUSION

This study created the THA-10 score and showed it to have clinically significant diagnostic utility in predicting 10-year THA conversion after HA for FAIS. Patients scoring ≥4 points were 13.2 times more likely to undergo THA conversion.

Patients Report Improved Functional Outcomes Following Puncture Capsulotomy Technique for Hip Arthroscopy at 5-Years

PURPOSE

(1) evaluate minimum 5-year functional outcomes, (2) assess secondary surgery rates, and (3) analyze post-operative complications after hip arthroscopy for labral tears secondary to femoroacetabular impingement using the puncture capsulotomy technique.

METHODS

This is a retrospective review of prospectively collected data from May 2014 to May 2019 that included patients ≥18 who underwent hip arthroscopy via puncture capsulotomy for labral tears and concomitant femoroacetabular impingement with five years of patient-reported outcome measure (PROM) surveys.

RESULTS

A total of 109 hips were included in this study (49.5% female; mean age±SD: 37.7±14.1), with a with a mean follow-up time of 61.0±1.58 months (range: 60-67 months)and a mean body mass index of 25.5±3.93 kg/m2. When compared to mean enrollment values, the mean modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific Subscale (HOS-SS), International Hip Outcome Tool-33 (iHOT-33) were all significantly improved (p<0.001) at five-year follow-up: (mHHS pre-op: 63.1±14.6 vs post-op: 88.9±14.6; HOS-ADL: 71.1±19.5 vs. 92.8±11.1; HOS-SS: 41.8±25.3 vs. 81.7±23.8; iHOT-33: 41.9±19.1 vs. 84.4±19.6), respectively. Furthermore, for mHHS, 83.8%% 71.4%, and 52.1% of patients achieved minimally clinically important difference (MCID), Patient Acceptable Symptomatic Scores (PASS) and Substantial Clinical Benefit (SCB), respectively. The rate of revision hip arthroscopy was 0% and conversion to total hip arthroplasty was 7.83%.

CONCLUSION

At minimum five year follow up, puncture capsulotomy results in significantly improved functional and clinically meaningful outcomes. Overall, patients reported minimal complication and conversion to total hip arthroplasty rates.

Similar Rates of Survivorship and Marginal Clinical Impact of Routine Interportal Capsular Repair Versus No Repair at 5 Years After Arthroscopic Correction of Femoroacetabular Impingement

PURPOSE

(1) To compare 5-year survivorship (avoiding repeat hip arthroscopy (HA)/total hip replacement conversion) between those undergoing routine capsular repair compared with where no repair was performed; (2) compare patient-reported outcome measures (PROMs) and achievability of metrics of clinically important improvement between these groups; and (3) evaluate the moderating influence of age and sex on outcomes.

METHODS

Review of prospectively collected data from an institutional hip preservation registry, of cases undergoing hip arthroscopy (HA) for femoroacetabular impingement between January 2011 and September 2018, with minimum 5-year follow-up, was undertaken. Cases undergoing routine interportal capsular repair (CR) were matched in a 1:1 ratio (age ± 2 years, sex, Tönnis grade) to hips with no capsular repair (NR). Exclusion criteria were dysplasia, Tönnis grade >1, age >50 years, and concomitant hip pathologies. Group survival was evaluated using Kaplan-Meier analysis and for levels of sex and age. Where revision surgery (repeat HA/total hip replacement) was avoided, PROMs (modified Harris Hip Score, University of California and Los Angeles Activity Scale [UCLA], Short Form 36 [SF-36]) were assessed at minimum 5 years, and proportion of cases achieving minimal clinically important difference (MCID) and substantial clinical benefit (SCB) determined.

RESULTS

In total, 285 CR cases were matched with 285 NR cases. The average age was 27.0 ± 5.9 years, and most patients (90%) were male. The overall total hip replacement rate was 0.7% (0.4% NR; 0.9% CR, P = .619) and was not significantly different between groups when adjusting for sex (χ2 = 0.474, P = .491), or age (χ2 = 0.463, P = .496). The overall repeat HA rate was 12.0% (12.9% NR; 11.1% CR, P = .538), which was not significantly different between groups when adjusting for sex (χ2 = 0.479, P = .489), or age (χ2 = 0.448, P = .503). Significant improvement in all PROMs was noted for both the NR and CR groups (P < .001 for all). At 5 years postoperatively, SF-36 was marginally greater for the NR group (P = .006, r = 0.169). No significant difference between groups at 5 years postoperatively were found: modified Harris Hip Score (P = .476), UCLA (P = .188). A greater proportion of CR cases achieved MCID in UCLA (69.4% vs 56.5%, P = .032, Φ = 0.131). MCID achievement rates were similar between groups for all other PROMs (P > .05). A greater proportion of patients in the NR group achieved SCB in SF-36 (54.0% vs 41.9%, P = .049, Φ = 0.127). SCB achievement rates were similar between groups for all other PROMs (P > .05).

CONCLUSIONS

Routine repair of an interportal capsulotomy makes no difference to survivorship at minimum 5 years post-HA compared with nonrepair, with marginal differences in PROMs, and achievability of MCID and SCB thresholds of clinically significant improvement. The impact of capsular management (repair/nonrepair) may be more apparent for specific patient cohorts rather than routine repair in all cases.

LEVEL OF EVIDENCE

Level III, retrospective matched comparative case series.

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.

Editorial Commentary: Complete Capsular Closure in Hip Arthroscopy Shows Superiority in Expected Value Decision Analysis Compared to Incomplete Capsular Closure

In all aspects of orthopaedic surgery, restoring native patient anatomy has shown improved outcomes in comparison to nonanatomic reconstructions. Particular attention has been paid to the hip capsule, as the complex of the iliofemoral, pubofemoral, and ischiofemoral ligaments, as well as the zona orbicularis and iliocapsularis, all play an essential role in hip stability, mechanics, and maintenance of intra-articular pressures. An anatomic approach toward hip arthroscopy also includes labral repair or reconstruction with preservation of the chondrolabral junction and cam resection. Multiple recent studies have revealed improved patient-reported outcomes at long-term (>10-year) follow-up, as well as reduced revision rates and less progression to total hip replacement with complete capsular repairs compared to incomplete closure or no capsular management following hip arthroscopy. We perform an interportal capsulotomy with labral-sided capsular traction sutures for the central compartment, followed by the T-capsulotomy along the femoral neck with femoral-sided traction sutures for the peripheral compartment. At the end of every case, we ensure an anatomic complete capsular closure of the entire T-capsulotomy using a combination of self-retrieving suture guns and curved self-suture passers, often tying 7 or more sutures.

Remplissage Using Tendon Graft Can Improve Impaired Suction Seal Caused by Over-resection During Femoroplasty in an Ovine Model

PURPOSE

To evaluate the effect of depth and location of femoral osteoplasty or the use of remplissage on the suction seal in a sheep hip model.

METHODS

The hips of 32 twelve-month-old sheep were used as a cam-type femoroacetabular impingement model. The subjects were divided into 4 groups, each undergoing a distinct surgical procedure: group I underwent a 5% cam resection at the head/neck junction, group II had a 10% cam resection at the head/neck junction, group III received a 5% cam resection from 5 mm proximal to the head/neck junction, and group IV underwent remplissage to replace the loss of the suction seal with an extensor tendon graft in the defected area after a 10% cam resection at the head-neck junction. Each specimen was subjected to a compression force of 200 N before the surgical procedure, followed by distraction. After surgery, the same biomechanical test was conducted on each sample, and the average peak force was calculated.

RESULTS

Suction seal force was statistically significantly lower in all groups compared with the intact state before the surgical procedure. The maximum decrease in suction seal force after the surgical procedure was observed in the 10% resection group. However, in the remplissage procedure after 10% resection, the suction seal force exceeded the value in the 5% resection group and even reached the value in the intact state. Although proximal over-resection affects suction seal force, we found that an increase in depth had a more significant impact on suction seal force than proximal over-resection.

CONCLUSIONS

The most significant decrease in the suction seal was observed in the group with 10% cam resection compared with the 5% cam resection and proximal over-resection groups. Remplissage using tendon grafts significantly enhanced the suction seal in the 10% resection group in the ovine model. CLINICAL RELEVANCE: This study offers experimental evidence on how femoral osteoplasty depth affects the suction seal, building on previous research on the labrum. Remplissage may provide an alternative solution to the irreversible effects of excessive resection by reversing the suction seal effect.

Cartilage Defects Are Negatively Associated With Long-Term Hip Survivorship Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 10-Year Follow-Up

PURPOSE

To identify the timing and risk factors associated with secondary surgery following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year minimum follow-up.

METHODS

A prospectively collected clinical repository was evaluated for cases of primary hip arthroscopy for FAIS between January 2012 and February 2013 with minimum 10-year follow-up. Patients who underwent secondary surgery were propensity matched 1:4 to patients who did not undergo secondary surgery, controlling for age, sex, and body mass index (BMI). The groups were compared on demographics, radiographs, intraoperative findings, operative procedures, and patient-reported outcomes. A Kaplan-Meier survivorship curve was generated. Among the reoperation-free survivors, minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) achievement were recorded for Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and Visual Analog Scale for Pain (VAS Pain).

RESULTS

Twenty-four reoperation patients (67% female; age 40.1 ± 14.3 years; BMI 27.2 ± 5.5) were matched to 96 reoperation-free patients (62% female; age 37.0 ± 10.8 years; BMI 25.2 ± 4.7, P ≥ .111). Mean follow-up was 10.3 ± 0.2 years. No preoperative demographic differences were found between groups. The reoperation group showed more high-grade cartilage defects on the acetabulum and femoral head (33% vs 8%, P = .004; 29% vs 7%, P = .007). A bimodal distribution of time to reoperation was evidenced independent of the secondary surgery performed. Among the reoperation-free survivors, MCID and PASS achievement was as follows: HOS-ADL (69.1%, 62.1%), HOS-SS (69.9%, 74.4%), mHHS (73.3%, 58.1%), iHOT-12 (n/a, 63.8%), and VAS-Pain (80.2%, 62.6%).

CONCLUSIONS

Patients requiring reoperation following primary hip arthroscopy for FAIS demonstrated more severe cartilage defects and a bimodal distribution of time to reoperation.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Patients Aged 40 Years and Older Demonstrate Durable and Comparable Results to Patients Aged Less Than 40 Years After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity Matched Study at Minimum 10-Year Follow-Up

PURPOSE

To compare clinical outcomes and rates of secondary surgery, including revision hip arthroscopy and conversion to total hip arthroplasty (THA), after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients ≥40 years of age at minimum 10-year follow-up compared with a propensity-matched control group of patients <40 years.

METHODS

A retrospective cohort study was performed for patients who underwent primary hip arthroscopy for FAIS between January 2012 and February 2013. Patients ≥40 years old were propensity matched in a 1:1 ratio by sex and body mass index to patients <40 years old. Patient-reported outcomes (PROs) including Hip Outcome Score for Activities of Daily Living and Sports-Specific subscales, modified Harris Hip, International Hip Outcome Tool-12, and Visual Analog Scale for Pain and Satisfaction were collected. Rates of minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) achievement at 10 years were evaluated and compared between groups. Rates of secondary surgery including revision hip arthroscopy and conversion to THA were evaluated. Gross survivorship between cohorts was evaluated using a Kaplan-Meier curve.

RESULTS

Fifty-three patients aged ≥40 (age 48.3 ± 5.8 years) were successfully matched to 53 patients aged <40 (age: 28.9 ± 7.2, <0.001). There were no other preoperative group differences regarding patient demographics, characteristics, or radiographic findings. Both groups demonstrated significant improvement regarding all PROs at a minimum of 10 years' follow-up (P < .001 for all). No significant difference was noted between cohorts regarding any delta (preoperative to 10-year postoperative) scores (P > .05 for all). High rates of MCID and PASS achievement were achieved in both cohorts, with no significant differences in any PRO measure (P > .05 for all). No significant differences in rates of complications (age ≥40: 2.0%, age <40: 7.7%, P = .363), rates of revision (age ≥40: 7.5%, age <40: 9.4%, P = .999), or conversion to THA (age ≥40: 13.2%, age <40: 3.8%, P = .161) were identified. On Kaplan-Meier analysis, no significant difference (P = .321) was demonstrated in overall gross survivorship between cohorts.

CONCLUSIONS

Patients with age ≥40 with FAIS undergoing primary hip arthroscopy demonstrated durable and comparable 10-year PRO and rates of MCID and PASS achievement compared with a propensity-matched cohort of age <40 counterparts.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Patient Factors Influencing Outcomes at 12-Year Follow-up of Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement has increased in popularity since the early 2000s when it was first described, although only a few midterm follow-up studies have been published.

PURPOSE

To describe the outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement at a mean 12-year follow-up and to determine the risk factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The Non-Arthritic Hip Score (NAHS) and a radiographic evaluation were completed preoperatively and at midterm follow-up. Participants were divided into 2 groups according to their clinical evolution. The success group consisted of patients whose NAHS at the final follow-up was above the established Patient Acceptable Symptom State (PASS) threshold of 81.9, whereas patients who underwent a second surgical intervention or did not reach the PASS threshold at final follow-up were assigned to the failure group. These groups were compared to identify preoperative differences in demographic, pathological, and surgical factors.

RESULTS

A total of 95 hips were included, after 23 were lost to follow-up (80.5% follow-up). At a mean follow-up of 12.1 years (range, 9.2-16.0 years), 9 hips required total hip arthroplasty (9.5%), 5 required revision hip arthroscopy (5.3%), 29 did not achieve the NAHS PASS threshold (30.5%), and 52 achieved the NAHS PASS threshold (54.7%). The mean NAHS was 82.4 at final follow-up compared with 66.9 preoperatively (mean difference = 15.5; P < .001). Higher mean body mass index (24.9 vs 23.0; P = .030), older age (30.0 vs 27.2; P = .035), and inferior preoperative lateral joint space width (3.9 vs 4.4; P = .019) were associated with inferior prognosis in the failure group versus success group. Osteoarthritis progression was observed in 69.2% of the failure group and in 34.8% of the success group (P = .082). Labral ossification was observed in 78.3% of all patients, and its lateral projection length was statistically associated with failure (P = .015).

CONCLUSION

At a mean 12-year follow-up, hip arthroscopy for femoroacetabular impingement led to significant clinical improvement, with 55% PASS achievement. In total, 31% of patients were below the PASS threshold, 5% had revision arthroscopy, and only 9% had conversion to total hip arthroplasty for a 45% global failure rate. Increased body mass index, older age, and smaller preoperative lateral joint space width were significant negative prognostic factors. Postoperative degenerative changes were highly prevalent and demonstrated association with failure.

Eighty-One Percent of Unrepaired Interportal Capsulotomies Showed Healed Capsules on Magnetic Resonance Imaging 5 Years After Primary Hip Arthroscopy

Purpose

To evaluate whether unrepaired interportal capsulotomy presents with capsular defect on magnetic resonance imaging (MRI) 5 years after primary hip arthroscopy and to determine its effect on functional results and findings of osteoarthritis on radiographs or MRI scans.

Methods

Patients with femoroacetabular impingement (without arthritis or dysplasia) were retrospectively reviewed after arthroscopic labral repair or debridement and femoroplasty through interportal capsulotomy without closure. Patients were assessed preoperatively and at a minimum of 5 years postoperatively using patient-reported outcomes (Hip Outcome Score-Activities of Daily Living scale, modified Harris Hip Score, and visual analog scale pain score), radiographic measures, and MRI scans.

Results

Forty patients (42 hips) were deemed eligible for the study and were evaluated. Of the hips, 81% had healed capsules, whereas 8 (19%) had capsular defects on the latest MRI scan. There were 3 hips with subchondral edema in the defect group compared with 1 in the healed-capsule group (P = .01) on the latest MRI scan, which was not present on preoperative MRI (still positive on multivariate analysis when the preoperative alpha angle was also taken into consideration). Functional results did not differ between the groups (P > .05).

Conclusions

In this study, 81% of interportal capsulotomies healed without repair at 5 years after primary hip arthroscopy.

Clinical Relevance

Understanding the prevalence and implications of unhealed capsulotomies could encourage surgeons to be meticulous in capsular closure.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

BACKGROUND

Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD.

PURPOSE

To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups.

RESULTS

In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835).

CONCLUSION

Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.