Improved Functional Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy at Minimum 2-Year Follow-Up

Editorial Commentary: Comprehensive Treatment of Hip Acetabular Dysplasia Plus Labral and/or Cam Pathology With Combined Periacetabular Osteotomy and Hip Arthroscopy

Periacetabular osteotomy (PAO) is the agreed-upon treatment for symptomatic hip dysplasia in the skeletally mature patient. Many surgeons perform hip arthroscopy to address intra-articular damage around the time of the PAO. Other surgeons believe that correcting the dysplasia with the PAO unloads the soft tissues, which negates the need for arthroscopy. Current evidence is unclear as to whether hip arthroscopy, whether concomitant or staged, is needed when performing PAO for hip dysplasia. In the United States, the chosen approach often is determined by surgeon training, comfort level, and logistical issues. Over time, the chosen approach may change, as more surgeons are trained in both open and arthroscopic hip preservation. Certainly, some patients benefit from hip arthroscopy along with PAO for labral pathology and/or femoral cam deformity.

Primary and Revision Hip Arthroscopy in Borderline Hip Dysplasia Shows Comparable Outcomes at a Minimum 5-Year Follow-Up

PURPOSE

To compare patient-reported outcomes (PROs), achievement of clinically significant outcomes, and reoperation-free survivorship between primary and revision hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in propensity-matched borderline hip dysplasia (BHD) patients at a minimum 5-year follow-up.

METHODS

Patients with BHD, characterized by a lateral center-edge angle 18° to 25°, who underwent HA for FAIS with capsular repair by a single surgeon between January 2012 and June 2018 with a minimum 5-year follow-up were identified. Cases of revision HA were propensity-matched 1:2 to cases of primary HA, controlling for age, sex, and body mass index. A 1:2 ratio was chosen to maximize the number of included patients. Collected PROs included Hip Outcome Score-Activities of Daily Living and Sport Subscales, International Hip Outcome Score 12, modified Harris Hip Score, and Visual Analog Scale for Pain. Achievement of minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit for any measured PRO was compared between groups along with reoperation-free survivorship using Kaplan-Meier analysis.

RESULTS

Thirty-six revision HA hips (34 patients) were propensity-matched to 72 primary HA hips (70 patients). The groups were similar in age (31.5 ± 10.3 years vs 30.5 ± 11.2, P = .669), sex (69.4% female vs 70.8%, P = .656), and body mass index (25.7 ± 4.0 vs 25.5 ± 3.7, P = .849). The revision group showed a greater prevalence of prolonged preoperative pain (50.0% vs 27.8%, P = .032) compared with the primary group. A significant improvement in all PROs was observed for both groups with comparable PROs preoperatively and at the 5-year follow-up between groups (P ≥ .086). The revision and primary groups showed comparable minimal clinically important difference (95.0% vs 95.7%, P ≥ .999), patient acceptable symptom state (80.0% vs 83.6%, P = .757), and substantial clinical benefit (62.5% vs 70.7%, P = .603) achievement for any PRO. Comparable reoperation-free survivorship was observed (P = .151).

CONCLUSIONS

Propensity-matched patients with BHD undergoing primary and revision hip arthroscopy for FAIS achieved similar minimum 5-year PROs, clinically significant outcomes, and reoperation-free survivorship.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

What Are the Minimum Clinically Important Difference, Substantial Clinical Benefit, and Patient-Acceptable Symptom State Thresholds for the Modified Harris Hip Score and International Hip Outcome Tool 12 Among Patients Who Undergo Periacetabular Osteotomy?

BACKGROUND

The utility of patient-reported outcome measures (PROMs) has been well established, but their interpretation relies on population-specific definitions of meaningful improvement. As such, the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) thresholds have become prominent metrics in the orthopaedic evidence to ascribe clinical relevance to numeric PROM scores. Studies assessing outcomes of periacetabular osteotomy (PAO) relative to the MCID and PASS have previously evaluated patients against thresholds defined for hip arthroscopy for the treatment of femoroacetabular impingement or distribution-based MCID calculations. These scores may not accurately reflect the status or expectations of patients with a different symptom profile undergoing open hip preservation surgery.

QUESTIONS/PURPOSES

For patients treated with PAO, we sought to (1) define the MCID, SCB, and PASS threshold values for the mHHS (modified Harris hip score) and International Hip Outcome Tool 12 (iHOT-12) using anchor-based methods; (2) assess the validity of MCID and SCB estimates against minimal detectable change (MDC) values; and (3) determine the proportion of patients who achieved a clinically meaningful threshold.

METHODS

Between February 2011 and May 2023, a total of 690 patients underwent PAO for symptomatic acetabular dysplasia at one institution and were included in a longitudinally maintained hip preservation registry. The cohort used to define and validate MCID, SCB, and PASS threshold values consisted of those with a completed postoperative anchor questionnaire, which yielded 456 patients as potentially eligible. An additional 139 patients were excluded because of missing mHHS or iHOT-12 scores during the eligibility window (1 to 2 years postoperatively), leaving 70% (317 of 456) of patients to define and validate MCID, SCB, and PASS at a mean ± SD of 1.0 ± 0.3 years of follow-up. A minimum 1-year follow-up was chosen to reduce recall bias. The cohort for defining MCID, SCB, and PASS (94% [298 of 317] women, mean ± SD age at time of surgery 27 ± 8 years) included 21% (68 of 317) of patients with prior ipsilateral surgery. From those registry patients without complete anchor questionnaires, 37% (137 of 373) were identified with pre- and postoperative PROM scores at a mean ± SD of 1.0 ± 0.9 years of follow-up to form the sample for assessing the proportion of patients achieving a clinically meaningful threshold. The MCID, SCB, and PASS thresholds for the mHHS and iHOT-12 were calculated through an anchor-based approach, using area under the receiver operating curve to determine cut points that best identified positive responses, according to quality of life-based anchor questions. The MDC was calculated with confidence intervals (CIs) reflecting 80%, 90%, and 95% certainty to determine the smallest change in the PROM scores that can be considered above the level of measurement error. The validity of MCID estimates was assessed by confirming that they exceeded corresponding MDC values. The validity of SCB estimates were assessed by confirming that they exceeded corresponding MCID values. The proportion of patients achieving a clinically meaningful threshold was determined by calculating the percentage of patients who met the defined anchor-based scores.

RESULTS

The MCID, SCB, and PASS thresholds for the mHHS were 18, 23, and 71, respectively. The MCID, SCB, and PASS thresholds for the iHOT-12 were 26, 42, and 65, respectively. The MDC ranged from 8 to 12 for the mHHS and 10 to 16 for the iHOT-12. The MCID values for the mHHS and iHOT-12 exceeded corresponding values of the MDC at all CIs. The SCB thresholds exceeded all corresponding MDC and MCID values. Across the mHHS and iHOT-12, the proportion of patients who achieved an MCID at the first time point ranged from 60% to 73%, the proportion of patients who achieved the SCB ranged from 49% to 56%, and the proportion of patients who achieved the PASS threshold ranged from 55% to 79%. Among the cohort for defining MCID, SCB, and PASS, the proportion of patients achieving any MCID, SCB, or PASS was 79%, 66%, and 81%, respectively. Among the sample for assessing the proportion of patients achieving a clinically meaningful threshold, the proportion achieving any MCID, SCB, or PASS threshold was 74%, 58%, and 72%, respectively.

CONCLUSION

We found that using a sample of patients undergoing PAO, the anchor-based values for the MCID and SCB were generally larger than previous distribution- and anchor-based scores that have been defined for hip preservation, whereas PASS threshold scores were similar. All MCID and SCB thresholds exceeded corresponding MDC values, confirming these scores to be valid estimates. These metrics provide more rigorous, procedure-specific definitions for the evaluation of treatment success and failure after PAO. As anchor-based metrics are defined based on patients' perceptions, they should be used preferentially for postoperative assessment over distribution-based scores.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Editorial Commentary: Indications for Performing Hip Arthroscopy in Addition to Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip Require Clarification

The combination of hip arthroscopy and periacetabular osteotomy (PAO) has been proven safe and effective for addressing symptoms in patients with developmental dysplasia of the hip. As not every patient with dysplasia will require a hip arthroscopy to obtain desired clinical improvement in the setting of PAO, a challenge is identifying which patients require adjacent procedures (either via arthroscopic or open) to fully treat their hip pathology. Even though labral repair is the most reported arthroscopic procedure in cases of hip dysplasia, I would suggest that labral treatment is the least likely helpful component of hip arthroscopy in these cases. Not all patients with hip dysplasia will have restoration of their suction seal after arthroscopic repair or debridement of the labrum. On the basis of numerous studies demonstrating the effectiveness of PAO for hip dysplasia, labral pathology has unknown importance for either mechanical stability or for the long-term survivorship of the dysplastic hip and thus must be examined instead as a significant pain generator. Reorientation of the labrum out of the zone of injury, and/or desensitization of the labrum during labral stabilization, may alleviate pain generated from labral pathology in the setting of PAO for dysplasia. I find hip arthroscopy to be most helpful as a tool to assess articular cartilage and address femoroacetabular impingement in the most common forms of subspine or true femoral cam morphology, when present. One may argue that the best evaluation of femoroacetabular impingement only exists after PAO correction is achieved. In cases in which I am concerned about iatrogenic impingement from reorientation, particularly in the subspine area, I have intentionally delayed capsule closure to be able to assess and address residual impingement after PAO. Despite the fact that combining hip arthroscopy and PAO in a single stage is safe, we should approach hip arthroscopy and capsulotomy with trepidation, as capsular adhesions, iatrogenic articular cartilage damage, and disruption of capsular integrity are all risks best avoided if capsule violation is not necessary. Clearer definitions for labral pathology and indications for repair or debridement are required.

Is Periacetabular Osteotomy With Hip Arthroscopy Superior to Periacetabular Osteotomy Alone? A Systematic Review and Meta-Analysis

INTRODUCTION

There remains ongoing controversy regarding the optimal treatment strategy of hip dysplasia, with some advocating for the addition of hip arthroscopy to periacetabular osteotomy (PAO) to address concomitant labral tears. The purpose of this systematic review was to compare the clinical outcomes, complications, and joint preservation of PAO and PAO with hip arthroscopy.

METHODS

A literature search was done, and studies were included if they reported outcomes of PAO with concomitant hip arthroscopy, PAO with staged hip arthroscopy, or compared outcomes of PAO alone versus PAO with hip arthroscopy. A meta-analysis was conducted with respect to studies who compared preoperative to postoperative change in modified Harris Hip Score between PAO and PAO with hip arthroscopy.

RESULTS

Twenty studies were included in this review. Most patients demonstrated preoperative labral pathology. Pooled analysis of the postoperative change in modified Harris Hip Score showed no difference between PAO with concomitant hip arthroscopy and PAO alone (P = 0.238). Three of six studies comparing both surgical techniques demonstrated a notable postoperative improvement for select outcome scores for the PAO plus hip arthroscopy group but not for the PAO alone group. Of note, no studies demonstrated a notable improvement in the PAO alone group compared with PAO plus hip arthroscopy. The rates of complications and conversion to total hip arthroplasty for both procedures were notably similar.

CONCLUSION

Favorable and comparable clinical outcomes were observed for both PAO alone and PAO with hip arthroscopy. Although PAO with hip arthroscopy demonstrated statistically superior clinical outcomes for some measures, it was never inferior to PAO alone. Randomized controlled studies with extended follow-up are needed to better understand the potential difference in long-term outcomes and rates of conversion to total hip arthroplasty between these procedures.

Favorable Early Outcomes and High Clinical Benefit Achievement Rate With Concomitant Hip Arthroscopy and Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip

PURPOSE

To report minimum 2-year follow-up patient-reported outcomes (PROs), clinical benefit, and survivorship in patients who underwent concomitant hip arthroscopy and periacetabular osteotomy (PAO) for the surgical treatment of the developmental dysplasia of the hip (DDH).

METHODS

Prospectively collected data were retrospectively reviewed for patients who underwent hip arthroscopy with concomitant PAO between December 2015 and September 2022. Patients with baseline and minimum 2-year PROs were included. Exclusion criteria included those who underwent an isolated PAO or had a history of ipsilateral prior surgery. The PROs collected were Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The minimal clinically important difference (MCID) was reported. Survivorship was defined as nonconversion to total hip arthroplasty (THA).

RESULTS

Thirty patients were included (29 females and 1 male). The average age at the time of surgery was 27.48 ± 8.57 years, and the average body mass index was 23.97 ± 4.05. Further, 86.67%, 73.33%, and 100% underwent labral treatment, femoroplasty, and capsular closure, respectively. The preoperative lateral center-edge angle increased from 17.07° ± 4.40 to 33.24° ± 3.40 postoperatively (P < .001). At a minimum of 2-year follow-up, all PROs significantly improved from baseline (P < .001): HOS-ADL improved from 62.68 ± 16.18 to 91.66 ± 15.13, HOS-SSS from 38.96 ± 21.39 to 86.82 ± 19.56. Moreover, 90% and 93.33% achieved MCID for the HOS-ADL and HOS-SSS, respectively. No conversions to THA were reported.

CONCLUSIONS

At a minimum 2-year follow-up, the surgical management of DDH with PAO and concomitant hip arthroscopy demonstrated significant improvement in all PROs collected, with a high achievement rate for the MCID, and survivorship of 100%. These results suggest that, at short-term follow-up, this surgical approach seems to be safe and effective.

LEVEL OF EVIDENCE

Level IV, retrospective case-series.

Staged Hip Arthroscopy and Periacetabular Osteotomy in Active Patients Aged 45 Years and Older Produce Comparable Improvements in Outcome Scores to Younger Patients

PURPOSE

To determine staged hip arthroscopy and periacetabular osteotomy (PAO) mid-term outcomes in active patients aged 45 years and older compared with a younger group.

METHODS

All patients aged 45 years and older who underwent staged arthroscopy and PAO between 2015 and 2021 were retrospectively analyzed and compared with a case-matched control group of younger patients. All patients underwent at least 6 months of nonoperative management prior to surgery. Prior to PAO, all patients underwent hip arthroscopy to address any intra-articular pathology. The experimental group consisted of patients with dysplasia aged 45 years and older without significant osteoarthritis who underwent PAO and reported patient-reported outcomes for a minimum of 1 year postoperatively. Patient-reported outcomes were quantified using the International Hip Outcome Tool 12 (iHOT-12) score and Non-arthritic Hip Score (NAHS).

RESULTS

The cohort consisted of 35 patients (44 hips) with a mean age of 49.4 ± 3.8 years. The lateral center-edge angle significantly improved from preoperatively (20.1° ± 4.5°) to postoperatively (33.2° ± 3.2°, P < .001). The mean follow-up period in the PAO cohort aged 45 years and older was 2.80 years (standard deviation, 1.3 years) postoperatively. Patients reported significant improvements in the iHOT-12 score (36.6 ± 14.1 preoperatively vs 81.2 ± 21.0 at latest follow-up, P < .001) and NAHS (59.2 ± 15.5 preoperatively vs 87.4 ± 13.1 at latest follow-up, P < .001). The older cohort did not report significantly different iHOT-12 scores compared with the control group at any point, and age did not significantly affect either outcome score (P > .05).

CONCLUSIONS

Patients aged 45 years and older reported a statistically significant improvement in hip function and pain after staged hip arthroscopy and PAO, with outcome scores comparable to a younger cohort. Our findings show that appropriately selected older patients with dysplasia without significant pre-existing hip osteoarthritis experience clinically meaningful improvements in hip pain and function after hip preservation surgery.

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.

Arthroscopic Shelf Acetabuloplasty in the Treatment of Acetabular Dysplasia Combined With Cam-Type Femoroacetabular Impingement

Acetabular dysplasia is a hip condition characterized by abnormal development of the acetabulum, which can be present from birth or develop during childhood and may persist into adulthood. Mild or borderline acetabular dysplasia frequently is associated with cam-type femoroacetabular impingement in adults. Over time, the association of impingement and abnormal contact can lead to hip pain, cartilage damage, labral tears, and an increased risk of developing hip osteoarthritis. Several surgical treatments have been proposed: arthroscopic capsular plication, periacetabular osteotomy, or shelf acetabuloplasty. As mini-invasive shelf acetabuloplasty procedure has already proven its effectiveness, an arthroscopic shelf acetabuloplasty represents a less-invasive, less-risky procedure and allows during the same procedure to perform intra-articular resection of the femoral cam, labrum repair and capsular plication. This Technical Note describes an original technique of arthroscopic shelf acetabuloplasty that combines an outside-in arthroscopic approach for the intra-articular procedure (labral repair, femoroplasty, capsular plication) and an endoscopic shelf acetabulopasty with a tricortical iliac crest autograft secure with a single cannulated screw.

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.

Editorial Commentary: Concomitant Hip Arthroscopy and Periacetabular Osteotomy Treat Both the Cause and the Effects of Hip Dysplasia: The Best of Both Worlds

In the management of true hip dysplasia, the bony deformity is nearly always accompanied by, and often causal of, intra-articular pathology. It is strongly recommended to conduct a comprehensive preoperative evaluation as well as arthroscopic evaluation and treatment of coexisting hip joint conditions prior to performing an open Bernese periacetabular osteotomy. The osteotomy improves coverage of the femoral head and corrects the abnormal joint mechanics and loading patterns, which result in cartilage damage and subsequent osteoarthritis. Arthroscopy allows treatment of the intra-articular pathology. Combining the hip arthroscopy and periacetabular osteotomy procedures into a single surgical intervention, performed by either a single surgeon or a collaborative surgical team, allows us to address both the cause and the effects of dysplasia. This once-controversial combined technique has become a standard practice in the field with widespread adoption.