Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review

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.

Editorial Commentary: Hip Arthroscopy in Patients With Symptomatic Spine Pathology: Patient Education Supported by Diagnostic Injections Is the Key to Satisfactory Outcomes

Concomitant correctable and uncorrectable pathologies can impact outcomes after any orthopaedic procedure. The relationship between hip joint disorders and spine-related disorders has been increasingly recognized and reported in the literature. A number of studies have reported poorer outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement with associated symptomatic low back and sacroiliac dysfunction. A few studies, however, have noted that the magnitude of improvement after hip arthroscopy is similar between patients with and without spine pathology despite inferior outcomes associated with symptomatic spine disease. A couple of studies have contradicted these data and noted comparable outcomes after hip arthroscopy for isolated hip pain versus those with hip and spine pain. This is clearly a complex kinetic chain association, and the contradicting literature might be more about how we evaluate the data; set appropriate physician/patient expectations; perform a thorough workup, including diagnostic injections; and carefully navigate our way through this patient population rather than buying into a concrete conclusion one way or another. When faced with a patient population riddled with hip- and spine-related pathology, we are walking through a minefield of unpredictable patient-related outcomes. We need to use our evidence and experience-based map to avoid these mines of failure and safely march toward a successful outcome.

Hip Arthroscopy Patients with Concomitant Low Back Pain Show Clinical Improvement and Time-Dependent Survivorship Comparable to Those Without Low Back Pain: A Propensity Matched Study at Long-Term Follow-Up

PURPOSE

The purpose of this study was to evaluate patient-reported outcomes (PROs), achievement of clinically significant outcomes (CSOs), and reoperation-free survivorship at long-term follow-up following primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in patients with and without preoperative lower back pain (LBP).

METHODS

A repository was reviewed to identify patients who underwent primary HA for FAIS between 1/2012-5/2014 with 10-year follow-up. Exclusion criteria included prior ipsilateral hip surgery, concomitant procedures, congenital hip disorders, non-FAIS hip pathologies, Tönnis grade >1, history of platelet-rich plasma injections, and missing 10-year follow-up. Patients that self-reported preoperative, concomitant LBP were propensity-matched 1:1 to non-LBP patients by age, sex, and body-mass-index (BMI). PROs collected included Hip Outcome Score-Activities of Daily Living and Sports Subscale (HOS-ADL/HOS-SS), 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and Visual Analog Scale (VAS) for Pain and Satisfaction. Minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were compared. Subgroup analysis was conducted comparing females and males with LBP. Reoperation-free survivorship was compared with Kaplan-Meier analysis. An a priori power analysis determined sample size.

RESULTS

Overall, 69 hips in 67 LBP patients were matched to 69 hips in 67 non-LBP patients. Demographics were similar between groups, including age (39.22±10.3 vs. 38.99±10.7 years, P=0.90), sex (55.1% vs. 55.1% female, P=1.0), and BMI (26.15±4.6 vs. 26.36±5.1 kg/m2, P=0.80). Average follow-up duration was 10.43±0.4 years. The most common cause of LBP was degenerative lumbar or sacral conditions, including degenerative disc disease (DDD), degenerative joint disease (DJD), or spondylosis, accounting for 38.8% (26/69) of the cohort. Mean preoperative HOS-ADL (62.38±18.7 vs. 64.45±21.1, P=0.57), HOS-SS (37.83±22.6 vs. 45.67±24.7, P=0.09), mHHS (53.63±14.6 vs. 57.01±14.6, P=0.22), iHOT-12 (33.29±19.0 vs. 39.49±15.8, P=0.27), and VAS Pain (71.88±18.3 vs. 71.87±19.1, P=1.0) were similar between LBP and non-LBP patients. Additionally, the mean 10-year follow-up HOS-ADL (81.48±21.2 vs. 79.57±22.0, P=0.66), HOS-SS (66.87±31.3 vs. 67.36±30.4, P=0.94), mHHS (74.15±18.8 vs. 73.19±17.7, P=0.79), iHOT-12 (77.77±23.3 vs. 69.63±29.3, P=0.13), VAS Pain (23.98±25.0 vs. 32.19±28.4, P=0.11), and VAS Satisfaction (83.47±25.3 vs. 81.43±29.7, P=0.73) were similar between LBP and non-LBP patients. LBP and non-LBP patients had comparable MCID achievement for HOS-ADL (72% vs. 56%, P=0.13), HOS-SS (74% vs. 50%, P=0.06), mHHS (74% vs. 65%, P=0.47), iHOT-12 (83% vs. 72%, P=0.67), VAS Pain (89% vs. 75%, P=0.10), and any PRO (98% vs. 93%, P=0.32). Similarly, LBP and non-LBP patients had comparable PASS achievement for HOS-ADL (64% vs. 65%, P=1.0), HOS-SS (66% vs. 69%, P=0.83), mHHS (64% vs. 60%, P=0.84), iHOT-12 (65% vs 61%, P=0.84), VAS Pain (55% vs. 50%, P=0.71), and any PRO (76% vs. 80%, P=0.81). Subgroup analysis revealed no significant differences between females and males with LBP in preoperative or 10-year follow-up PROs as well as MCID and PASS achievement rates. Reoperation-free survivorship was comparable (P=1.0).

CONCLUSIONS

Patients undergoing primary HA for FAIS with concomitant LBP may achieve comparable PROs, CSOs, and reoperation-free time-dependent survivorship to patients without LBP at long-term follow-up.

LEVEL OF EVIDENCE

Retrospective, Matched Case-Control Study, Level III.

Patients with associated spine or other major joint pain have equivalent outcomes to patients with isolated hip pain after hip arthroscopy

OBJECTIVES

This study aims to evaluate the outcomes of patients following surgery diagnosed with femoroacetabular impingement syndrome (FAIS) who also experience low back and other joint pain compared to those with isolated hip pain.

METHODS

This is a retrospective cohort study of patients diagnosed with FAIS, with or without other joint pain, treated with hip arthroscopy from 2016 to 2020. Excluded cases were patients who had significant arthritis, irreparable labral tear requiring reconstruction, or were lost follow-up. Analysis was carried out in two ways, the first was according to the musculoskeletal morbidity (MSKM) scheme where patients were stratified into four different groups, and the second was according to the presence of any other joint or back pain (MSKM 2-4) compared to hip pain only (MSKM 1). Demographic data was analyzed between the groups. International Hip Outcome Tool 33 (iHOT-33) and Hip Outcome Score (HOS) were used as the primary and secondary outcome measures pre-operatively and a minimum of two years postoperatively.

RESULTS

A total of 131 patients were included in the study with 37 ​% males and 63 ​% females. Age (years) and body mass index (kg/m2) were similar between groups, whereas a statistically greater number of male participants were seen in the hip pain only group (MSKM 1). Pre-operatively, patients with isolated hip pain (MSKM 1), had a higher iHOT-33 scores (p ​< ​0.05), but no statistically significant differences were observed postoperatively between the groups. All groups demonstrated a statistically significant improvement in iHOT-33 and HOS scores postoperatively compared to pre-operatively (p ​< ​0.05), with 76 ​% meeting the threshold for minimum clinically important difference.

CONCLUSION

Patient-reported outcomes following hip arthroscopy for FAIS were significantly greater postoperatively for all patients, despite the presence of other joint or back pain. This study can assist in driving patient expectations following hip arthroscopy for FAIS.

LEVEL OF EVIDENCE

IV.

Rates of Return to Sexual Activity Are High in Patients Undergoing Hip Arthroscopy and Occurs Within 6 Weeks Postoperatively in Most Patients: A Systematic Review

PURPOSE

To provide an aggregate review of literature on (1) outcomes related to the quality of intercourse (frequency, postoperative pain during intercourse, postoperative sexual dysfunction) after hip arthroscopy and (2) patient-reported outcomes regarding postoperative sexual function after hip arthroscopy.

METHODS

This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. PubMed, Cochrane Controlled Register of Trials (CENTRAL), and Scopus were queried in March 2024. Studies were included if they reported qualitative or quantitative outcomes of sexual function after hip arthroscopy. Articles reporting nerve-related complications without mention of sexual function were excluded. Statistical significance was defined as P < .05.

RESULTS

Five studies reporting on 3,025 patients (1,899 [62.8%] women, 1,126 [37.2%] males) were included. The mean age ranged from 34 to 35.3 years, and mean follow-up periods ranged from 12 to 43 months. Two studies reported 98% and 95% of patients returning to sexual activity postoperatively. One study reported that the mean time for patients to resume sexual activity was 29.2 days, while another reported a median time of 6 weeks. One study reported significant improvements between mean preoperative and postoperative patient-reported outcomes in men using the International Erectile Function Score (20.3-21.9, P < .001) and women using the Female Sexual Function Scale (21.6-23.0, P < .001). Another study reported significant improvement in median patient scores for the Sexual Activity Question of the International Hip Outcome Tool-12 (35-70, P < .001). However, 3 studies reported residual pain related to intercourse after hip arthroscopy.

CONCLUSIONS

The reviewed literature showed that hip arthroscopy is associated with high rates of resumption of sexual activity within 4 to 6 weeks postoperatively, with significant improvement in sexual activity-related patient-reported outcomes. However, patients may expect some residual pain related to sexual function after surgery.

STUDY DESIGN

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

Hip Arthroscopy Patients With Lower Back Pain Show Delayed Clinical Improvement and Inferior Time-Dependent Survivorship: A Propensity Matched Study at Mid-Term Follow-Up

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at mid-term follow-up after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in patients with and without preoperative lower back pain (LBP).

METHODS

Patients with self-endorsed preoperative LBP who underwent HA for FAIS with mid-term follow-up were identified and propensity matched 1:1 to patients without back pain by age, sex, and body mass index (BMI). PROs collected preoperatively and at postoperative years 1, 2, and 5 included Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Subscale (HOS-SS), 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and Visual Analog Scale (VAS) for Pain. Achievement of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were compared. Survivorship was compared with Kaplan-Meier analysis.

RESULTS

In total, 119 patients with LBP were matched to 119 patients without LBP. Group demographic factors were as follows: age (37.4 ± 11.9 vs 37.6 ± 12.6 years, P = .880), sex (64.4% vs 67.7% female, P = .796), and BMI (25.3 ± 5.1 vs 25.3 ± 5.4, P = .930). Average follow-up duration was 6.0 ± 1.9 years. LBP patients showed similar preoperative PROs, yet lower 1-year scores for all PROs (P ≤ .044). At final follow-up, similar PROs were shown between groups (P ≥ .196). LBP and non-LBP patients had similar MCID achievement for HOS-ADL (59.3% vs 63.1%, P = .640), HOS-SS (73.9% vs 70.8%, P = .710), mHHS (66.7% vs 73.4%, P = .544), iHOT-12 (85.1% vs 79.4%, P = .500), and VAS Pain (75.6% vs 69.9%, P = .490). Groups also had similar PASS achievement for HOS-ADL (63.5% vs 61.3%, P = .777), HOS-SS (57.0% vs 62.5%, P = .461), mHHS (81.9% vs 79.1%, P = .692), iHOT-12 (54.6% vs 61.2%, P = .570), and VAS Pain (51.0% vs 55.4%, P = .570). Additionally, achievement of MCID ≥ 1 PRO (P ≥ .490) and PASS ≥ 1 PRO (P ≥ .370) was similar across groups. Conversion to total hip arthroplasty occurred in 3.4% of hips with LBP and 0.8% of hips without LBP (P = .370). Back pain patients demonstrated inferior time-dependent survivorship compared with patients without back pain on Kaplan-Meier survival analysis (P = .023).

CONCLUSIONS

Patients undergoing primary hip arthroscopy for FAIS with LBP achieve comparable PROs and clinically significant outcomes to patients without back pain at mid-term, despite lower 1-year PRO scores. LBP patients show inferior reoperation-free time-dependent survivorship compared with those without LBP.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Editorial Commentary: Hip Arthroscopy in Patients With Spine Pain: Outcomes Vary Compared to Patients With Isolated Hip Pathology, but Many Hip-Spine Patients Do Just as Well

Low back pain present concurrently with hip impingement or labral pathology is frustrating for both patient and surgeon. It is difficult to distinguish true hip pathology from secondary low back symptoms, even with the use of diagnostic injections, cross-sectional imaging, electromyography, and/or nerve conduction studies. In addition, even properly indicated hip arthroscopy can exacerbate sciatic nerve dysfunction, a known complication from traction, and altered gait in the early postoperative period can aggravate sacroiliac and lumbar pathology. Moreover, difficult results vary in these patients after hip arthroscopy and show higher revision rates and less improvement in functional scores compared to patients with isolated hip pathology. Nevertheless, appropriately selected "hip-spine" patients show significant benefit from hip arthroscopy. Provided they have appropriate counseling, many hip-spine patients can undergo hip arthroscopy and experience a satisfying, durable outcome, and improvements at 1 year postoperatively are shown to be maintained at 5 or more years.

Demographic Disparities and Outcomes Following Hip Arthroscopy: Exploring the Impact of Social Determinants of Health in Femoroacetabular Impingement Syndrome

BACKGROUND

The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression.

RESULTS

In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all).

CONCLUSIONS

Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile.

LEVEL OF EVIDENCE

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

Editorial Commentary: Patients With Lumbar Pathology or Ipsilateral Knee Pathology Improve After Hip Arthroscopy, but Outcomes Are Not as Good as in Patients With Femoroacetabular Impingement Syndrome Without Concomitant Pathology

From the lumbar spine to foot, the joints of the lower extremity are all intimately connected. Their movements are synchronized in a complex biomechanical dance. Pain in one joint tends to affect the joint above and joint below. Understanding the influence of adjacent-joint disease on the hip can help us better counsel patients undergoing hip surgery. Low-back pathology has been shown to negatively influence outcomes after hip arthroscopy. Ipsilateral knee pain appears to do the same. Patients with femoroacetabular impingement syndrome with ipsilateral knee pain should be counseled that their outcomes may not be quite as good as those without knee pain, but they should be able to expect meaningful improvement of their symptoms, both at the hip and at the knee after hip arthroscopy.

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

BACKGROUND

The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion.

PURPOSE

To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA).

RESULTS

A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up.

CONCLUSION

After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.