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

Ten-year outcomes of hip arthroscopy for femoroacetabular impingement with osteoarthritis: Sustained functional benefits but high conversion to total hip arthroplasty

PURPOSE

To evaluate the long-term clinical and radiographic outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients with mild to moderate osteoarthritis (OA). The hypothesis is that patients with FAIS and mild to moderate OA would experience sustained improvements in iHOT-12 at 10-year follow-up, despite natural OA progression.

METHODS

This prospective cohort study included 75 patients (80 hips) with FAIS and radiographic signs of mild to moderate OA (Tönnis grade 1 or 2) who underwent hip arthroscopy between November 2011 and December 2012. The International Hip Outcome Tool (iHOT-12) was the primary outcome at a minimum of 10-year follow-up. Radiographic progression of OA using Tönnis classification and conversion to THA were recorded. Statistical analysis of patient-reported outcome measures (PROMs) was performed with Wilcoxon signed-rank test. Relative risk assessment (RR) for conversion to THA for Tönnis grade 1 and 2 was reported.

RESULTS

At 10-year follow-up, 26 patients (29 hips) had undergone THA, resulting in a hip survivorship of 59% while 41% of hips progressed to THA by 10 years. The mean time to THA was 7.1 years (±1.5). Patients with Tönnis grade 2 at baseline had a significantly higher risk of THA compared with Tönnis grade 1 (RR = 3.44, 95% CI: 1.81-6.55, p < 0.001). Among non-THA patients, 79% reported satisfaction with surgery. The iHOT-12 score improved from 41.4 (±17.1) preoperatively to 71.0 (±26.7) at follow-up (p < 0.001), with 67% of patients exceeding the minimal important change (MIC) threshold. Radiographic progression of Tönnis grade was observed in four hips.

CONCLUSION

Hip arthroscopy in patients with FAIS and mild to moderate OA provides substantial long-term functional benefits for those patients not having to undergo THA. However, preoperative OA severity is a key predictor of THA conversion with nearly two-fifths of hips requiring THA within 10 years.

LEVEL OF EVIDENCE

Level IV, case series.

Identifying Independent Predictors of Achieving Clinically Significant Outcomes After Contemporary Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome at a Minimum 10-Year Follow-up

BACKGROUND

Patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) have been shown to achieve clinically significant outcomes (CSOs) at high rates. However, limited studies, to date, have identified independent predictors of achieving CSOs at a minimum 10-year follow-up, and even fewer studies have reported on patients treated with contemporary hip arthroscopic techniques, including chondrolabral preservation, surgical correction of FAIS morphology, and capsular repair.

PURPOSE

To identify independent predictors of achieving minimum 10-year CSOs after contemporary hip arthroscopic surgery for FAIS with chondrolabral preservation, surgical correction of FAIS morphology, and capsular repair.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients undergoing primary contemporary hip arthroscopic surgery for FAIS between January 2012 and November 2013 with a minimum 10-year follow-up were identified. Patient-reported outcomes (PROs) collected included scores for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, International Hip Outcome Tool-12, modified Harris Hip Score, and visual analog scale for pain. Cohort-specific thresholds for the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) were determined, and achievement rates were recorded. Patients achieving and not achieving each CSO for any PRO measure were compared. Stepwise multivariate logistic regression was used to identify independent predictors of achieving the MCID, PASS, and SCB for any PRO measure, with the odds ratio (OR) recorded.

RESULTS

A total of 294 patients with a minimum 10-year follow-up were included in this study. The mean age was 33.8 ± 12.3 years, and the mean body mass index was 25.0 ± 4.8 kg/m2. Most patients were female (60.2%). The reoperation-free survivorship rate was 85.0%. Achievement rates for the MCID, PASS, and SCB were 91.4%, 77.6%, and 71.6%, respectively. Independent predictors of achieving CSOs were age (OR, 0.97-0.98; P ≤ .039), sport participation (OR, 1.84-2.18; P ≤ .042), psychiatric history (OR, 0.46-0.47; P ≤ .041), and high-grade chondral defects (OR, 0.25-0.39; P ≤ .019).

CONCLUSION

Independent predictors of achieving 10-year CSOs after contemporary hip arthroscopic surgery with chondrolabral preservation, surgical correction of FAIS morphology, and capsular repair were younger age, the presence of sport participation, the absence of a psychiatric history, and the absence of chondral defects.

Editorial Commentary: Older Age, Higher Body Mass Index, and Female Sex May Be Associated With Inferior Long-Term Outcomes in Patients Undergoing Primary Hip Arthroscopy for Femoroacetabular Impingement, but With Modification of Risk Factors, Positive Results Can Still Be Achieved

Hip arthroscopy is a successful treatment option for patients with femoroacetabular impingement syndrome, with favorable reported outcomes at >10-year follow-up. Still, a minority of patients experience persistent symptoms postoperatively and potentially require reoperation, such as revision hip arthroscopy or conversion to total hip arthroplasty. There is strong evidence suggesting that patients with pre-existing osteoarthritis (Tönnis grade 2 or greater) at the time of primary surgery are at risk for inferior long-term clinical outcomes after hip arthroscopy. Higher body mass index (BMI), advanced age, and female sex have also been shown to be negatively associated with postoperative outcomes and increase the risk of reoperation in patients undergoing hip arthroscopy surgery. Of concern, nearly 42% of patients with femoroacetabular impingement syndrome undergoing hip arthroscopy in the United States are considered overweight or obese. With that being said, older age, high BMI, and female sex are not contraindications for undergoing primary hip arthroscopy. Older patients without the presence of degenerative changes can still achieve reliable outcomes after hip arthroscopy surgery. High BMI is a modifiable risk factor that can be optimized before proceeding with surgery. Female patients may be more likely to have microinstability, which can be addressed by hip capsulotomy repair. Favorable outcomes may be achieved with appropriate preoperative counseling, optimization of modifiable risk factors, and a patient-specific approach.

Sport Participation Is Associated with Superior 10-Year Patient Acceptable Symptom State Achievement Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Sport participation has been associated with favorable outcomes following hip arthroscopy (HA) for femoroacetabular impingement (FAI) at short- and mid-term follow-up; however, few studies have evaluated the 10-year outcomes in this population. The purpose of this study was to compare patient-reported outcome measures (PROMs), the achievement of clinically significant outcomes, and reoperation-free survivorship between patients with and without regular preoperative sport participation who underwent HA for FAI and had a minimum of 10 years of follow-up.

METHODS

Data were prospectively collected for patients who underwent primary HA for FAI between January 2012 and September 2013. Patients who participated in weekly sport participation at the time of surgery ("athletes") were matched 1:1 to patients who denied sport participation ("nonathletes"), controlling for age, sex, and body mass index (BMI). Preoperative and 10-year postoperative PROMs were collected, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-Sports) subscales, the modified Harris hip score (mHHS), and the visual analog scale for pain (VAS Pain) and satisfaction (VAS Satisfaction). Patient acceptable symptom state (PASS) achievement and reoperation-free survivorship were compared between the groups.

RESULTS

Sixty-four athletes were matched to 64 nonathletes of similar age, sex, and BMI (p ≥ 0.411). In the athlete group, 85.9% were recreational-level athletes. The groups had similar preoperative PROMs, except for the HOS-ADL subscale, where the athlete group demonstrated a higher preoperative score (67.8 ± 16.7 versus 59.9 ± 21.1, p = 0.029). Both groups demonstrated a significant improvement in all PROMs (p < 0.001) at the minimum 10-year follow-up10.3 ± 0.4 years). At the time of the final follow-up, the athlete group demonstrated significantly higher scores across all of the measured PROMs (p ≤ 0.036). Athletes showed a higher cumulative PASS achievement compared with nonathletes for the HOS-ADL subscale (73% versus 50%, p = 0.033), the HOS-Sports subscale (85% versus 61%, p = 0.010), the mHHS (69% versus 43%, p = 0.013), and the VAS Pain (78% versus 51%, p = 0.006). Reoperation-free survivorship frequencies were 87.5% and 82.8%, respectively (p = 0.504).

CONCLUSIONS

Athletes who underwent contemporary HA for FAI showed superior PROMs and PASS achievement compared with nonathletes at the 10-year follow-up. Athletes and nonathletes showed reoperation-free survivorship frequencies of 87.5% and 82.8%, respectively.

LEVEL OF EVIDENCE

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

Six-Month Outcomes Correlate With 10-Year Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To identify whether 6-month outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) correlate with outcomes at minimum 10-year follow-up.

METHODS

Patients who underwent primary hip arthroscopy for FAIS from 2012 to 2013 were reviewed and included if they had 6-month and minimum 10-year follow-up. Patient-reported outcome (PRO) measures included the Hip Outcome Score Activities of Daily Living (HOS-ADL) subscale, Hip Outcome Score Sports-Specific (HOS-SS) subscale, modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. We compared 6-month and 10-year outcome scores and analyzed the relations between 6-month and 1-, 2-, 5-, and 10-year outcome scores using Pearson correlation coefficients (r). Six-month scores and clinically significant outcome achievement were then compared with 10-year clinically significant outcome achievement and reoperations, including revision hip arthroscopy and conversion to total hip arthroplasty (THA), using logistic regressions and the Fisher exact test.

RESULTS

This study included 60 patients (60.0% female sex; mean age, 36.0 ± 12.2 years). The mHHS, VAS pain score, and VAS satisfaction score significantly improved from 6-month to 10-year follow-up (P ≤ .021), whereas the HOS-ADL and HOS-SS did not (P ≥ .072). There were significant correlations between 6-month and 10-year scores for the HOS-ADL (r = 0.505), HOS-SS (r = 0.592), and mHHS (r = 0.362) (P ≤ .022 for all), as well as significant correlations between 6-month and 1-, 2-, and 5-year scores (P ≤ .014 for all). The 6-month HOS-ADL, HOS-SS, and mHHS were all significantly associated with their respective 10-year achievement of the patient acceptable symptom state (PASS) (P ≤ .044). Furthermore, 6-month HOS-ADL and mHHS were significantly associated with THA conversion (P ≤ .041). Comparable 6-month and 10-year achievement of the minimal clinically important difference (96.5% vs 97.8%, P > .999) and PASS (85.2% vs 87.5%, P > .999) for any PRO was observed.

CONCLUSIONS

After hip arthroscopy for FAIS, patients' 6-month HOS-ADL and mHHS were significantly associated with their 10-year PROs, PASS achievement, and THA conversion, although correlation strengths decreased with increasing time from surgery.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Osteochodral Autograft and Allograft Show Favorable Outcomes for High-Grade Hip Femoral Cartilage Lesions, but Caution Is Required for Impaction Injuries and Osteonecrosis

Articular cartilage defects of the hip pose therapeutic challenges. Among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome, more than 20% may have partial- or full-thickness chondral damage, and patients with high-grade (International Cartilage Repair Society grade 3 or 4) damage who undergo arthroscopic treatment of femoroacetabular impingement syndrome have higher rates of reoperation at 10-year follow-up. Arthroscopic and open techniques have been developed to translate cartilage restoration options initially developed in the knee for use in the hip. Arthroscopic options include chondroplasty, microfracture, biologic cartilage scaffolds, autologous chondrocyte implantation, and minced cartilage autograft (albeit more commonly in the acetabulum than the femoral head). Open techniques include autologous chondrocyte grafting, osteochondral autograft transfer (including mosaicplasty), osteochondral allograft transplantation, and arthroplasty. Open osteochondral allograft and autograft transplantation show improved patient-reported outcomes and forestall arthroplasty in young patients with high-grade cartilage defects of the femoral head. A recent review shows survivorship of 70% to 87.5% for allograft and 61.5% to 96% for autograft. At the same time, outcomes are not universally positive, particularly for patients with posttraumatic impaction injuries and high-grade osteonecrosis. Until further data better clarify the indications and contraindications, widespread adoption of open cartilage transplantation to the femoral head should be approached with caution, especially for older patients, in whom the gold standard of total hip arthroplasty has excellent survivorship at long-term follow-up.

The Association of Preoperative Hip Pain Duration With Delayed Achievement of Clinically Significant Outcomes After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

BACKGROUND

Patients with hip pain ≥2 years before hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) have been shown to achieve inferior short-term and midterm outcomes compared with patients with a shorter pain duration, although there is limited literature that has evaluated the time to achieve clinically significant outcomes (CSOs) in this population.

PURPOSE

To compare the time to achieve CSOs after hip arthroscopic surgery for FAIS in patients with and without prolonged hip pain and to identify independent predictors of the delayed achievement of CSOs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopic surgery for FAIS between January 2012 and July 2019 with 6-month, 1-year, and 2-year Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Subscale (HOS-SS) scores were identified. Patients with prolonged hip pain (preoperative duration ≥2 years) were propensity score matched to a control group (preoperative duration <2 years), controlling for age, sex, and body mass index (BMI). The times to achieve the minimal clinically important difference and Patient Acceptable Symptom State were compared between groups using Kaplan-Meier survival analysis. Multivariate Cox regression considering age, sex, BMI, pain duration, activity level, and chondral status was used to identify independent predictors of the delayed achievement of CSOs.

RESULTS

A total of 179 patients with prolonged hip pain were matched to 179 control patients (mean pain duration, 60.5 ± 51.2 vs 9.7 ± 5.1 months, respectively; P < .001) of a similar age, sex, and BMI (P≥ .488) with similar baseline HOS-ADL and HOS-SS scores (P≥ .971). The prolonged hip pain group showed delayed achievement of the minimal clinically important difference and Patient Acceptable Symptom State for both the HOS-ADL and HOS-SS on Kaplan-Meier analysis (P≤ .020). On multivariate Cox regression, hip pain duration ≥2 years was shown to be an independent predictor of the delayed achievement of CSOs, with hazard ratios ranging from 1.32 to 1.65 (P≤ .029). Additional independent predictors of the delayed achievement of CSOs included increasing age, increasing BMI, female sex, self-endorsed weekly participation in physical activity, and high-grade chondral defects (hazard ratio range, 1.01-4.89; P≤ .045).

CONCLUSION

Findings from this study demonstrate that preoperative hip pain duration ≥2 years was an independent predictor of the delayed achievement of CSOs after primary hip arthroscopic surgery for FAIS.