Hip Arthroscopy for Femoroacetabular Impingement: Minimal Clinically Important Difference Rates Decline From 1- to 5-Year Outcomes

Effects of Depression and/or Anxiety on the Outcomes of Hip Arthroscopy for Femoroacetabular Impingement and Labral Tears: A Minimum 5-Year Follow-up Study

BACKGROUND

Depression and anxiety are recognized as adverse prognostic factors in various orthopaedic surgical interventions. The aim of this study is to report the intermediate-term outcomes of hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and labral tears in patients with depression and/or anxiety.

METHODS

Data were retrospectively analyzed for patients with a self-reported history of depression and/or anxiety who had undergone primary hip arthroscopy for the treatment of FAI and labral tears from 2008 to 2018. Included patients had at least 1 of the following patient-reported outcome (PRO) scores: the modified Harris hip score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), patient satisfaction, Short Form 12-Mental (SF-M), Veterans RAND 12 Item-Mental (VR-M), and visual analog scale (VAS) for pain, or a revision procedure during the study period. Patients were propensity-matched with a benchmark control group of patients without depression and/or anxiety, in a 1:1 ratio, to control for confounding variables. Clinically relevant thresholds, revision procedures, and survivorship rates were also included in the analysis.

RESULTS

One hundred and twenty-five hips in patients with depression and/or anxiety were included in the study and were successfully matched to 125 control hips in patients without depression and/or anxiety. The depression/anxiety cohort demonstrated significant improvement in all functional outcome scores, with a magnitude of improvement that was comparable with that in the control group. However, the depression/anxiety group started with significantly lower preoperative scores for the HOS-SSS, SF-M, and VR-M; ended with lower intermediate-term scores for the mHHS, NAHS, HOS-SSS, SF-M, and VR-M; and had lower rates of achievement of patient-acceptable symptom state (PASS) thresholds for the mHHS and HOS-SSS. There was no significant difference between the 2 groups with regard to secondary procedures and complications.

CONCLUSIONS

Hip arthroscopy for the treatment of FAI and labral tears in patients with depression and/or anxiety resulted in significant intermediate-term improvements in functional and health-related quality-of-life scales. However, compared with a benchmark control group, the functional scores in this patient population started lower and ended lower. In addition, the patients in the depression/anxiety cohort had a lower rate of achieving PASS thresholds than those in the control group.

LEVEL OF EVIDENCE

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

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.

Editorial Commentary: Time to Recovery Varies After Hip Gluteus Repair: Patient Expectations Should Be Set Accordingly

Patients undergoing endoscopic gluteus medius and/or minimus repair with concomitant arthroscopic labral management have been reported to achieve excellent improvement in symptoms and outcome at as far as 5- to 10-year long-term follow-up. Although clinical outcomes at 2 years and onward are successful, few studies investigate how quickly patients improve after surgery. Most patients undergoing gluteus medius and/or minimus for predominantly partial-thickness tears achieve minimal clinically important differences as early as 6 months postoperatively, and a minimum of 1 year is needed for most patients to achieve a patient acceptable symptomatic state. From a patient counseling and satisfaction standpoint, time to recovery is of high importance.

The Definition of Failure in Hip Arthroscopy May Include Factors Outside of Reoperation: A Systematic Review

Purpose

To perform a systematic review about the varying definitions of "failure" of hip arthroscopy (HA) in the current literature and to provide a recommendation for the standardization of defining failure of HA.

Methods

A systematic search of electronic databases was conducted to identity Level I-IV clinical studies on HA failure published between January 2016 and July 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of studies of patients who underwent an arthroscopic hip procedure and included a definition of failure. Studies with patients who underwent open hip procedures and non-full-text articles were excluded.

Results

Of 1,290 titles, 85 (6.6%) met inclusion criteria and were analyzed in this review. The most common definition of HA failure used was the need for any subsequent ipsilateral hip surgery (80/85, 94.1%). Among studies that noted reoperation as a cause for failure, conversion to total hip arthroplasty was most frequently cited (66/85, 77.6%) followed by any other reoperation on the ipsilateral hip, including repeat HA, hip resurfacing, and hip periacetabular osteotomy (65/85, 76.5%). Multiple studies used subjective patient-reported outcomes, with use of the modified Harris Hip Score being the most common (17/85, 20%).

Conclusions

There are numerous definitions of the term "failure" of HA used by authors in the peer-reviewed literature. A standardized definition of HA failure should be multifactorial. It may include any unplanned subsequent procedures; patient-reported outcomes with emphasis on minimal clinically important difference, substantial clinical benefit, and/or patient acceptable symptom state values; and the inability to return to normal function or sports.

Level of Evidence

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

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage

BACKGROUND

Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS).

PURPOSE

To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups.

RESULTS

In total, 94 patients (mean age, 41.9 ± 14.2 years) were included with a mean follow-up duration of 6.1 ± 0.9 years. Of these patients, 40.4% had no acetabular overcoverage, 36.2% had lateral overcoverage, and 23.4% had global overcoverage. There was no difference between groups with respect to percentage of patients who underwent reoperation for either revision arthroscopy or conversion to total hip arthroplasty (28.9% for the normal acetabular coverage group, 29.4% for the lateral overcoverage group, and 31.8% for the global overcoverage group; P = .971). Among patients for whom primary hip arthroscopy did not fail, there was no difference in 5-year functional outcomes between groups. Postoperative LCEA >40° (β = -13.3; 95% CI, -24.1 to -2.6; P = .016), female sex (β = -14.5; 95% CI, -22.7 to -6.2; P = .001), and higher body mass index (β = -1.9; 95% CI, -2.8 to -1.0; P < .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score.

CONCLUSION

There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.

Hip Spine Syndrome Negatively Impacts Arthroscopic Outcomes in the Management of Femoroacetabular Impingement Syndrome: A Systematic Review

To determine whether the presence of spine pathology affects clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in the setting of hip-spine syndrome (HSS) METHODS: A systematic review of PubMed and Cochrane was conducted. Primary research articles evaluating patient-reported outcomes (PRO) after hip arthroscopy for FAIS in the presence of concomitant spine pathology were considered RESULTS: Literature review identified 12 studies meeting criteria. In 2109 FAIS patients undergoing hip arthroscopy, 591 had concomitant spine pathology. Baseline PROs in the hip-spine (modified Harris Hip Score [mHHS]: 39.8-65.29 vs 56.9-78.8, 8 studies; non-arthritic hip score [NAHS]: 42.2-51.5 vs 68.2-75.2, 4 studies; hip outcome score-activities of daily living [HOS-ADL]: 45.9-71.1 vs 49.3-89.51, 9 studies; hip outcome score-Sport (HOS-Sport): 22.8-49.6 vs 50.6-73.1, 3 studies; international hip outcome tool-33 [iHOT-12]: 38.0 vs 66.0, 1 study; visual analog scale [VAS] Pain: 6.43-6.56 vs 1.18-3.60, 3 studies; VAS Satisfaction: 7.18-7.46 range at follow-up, 2 studies) and control (mHHS: 39.3-64.9 vs 70.2-92.6, 6 studies; NAHS: 42.8-54.2 vs 74.0-87.1, 4 studies; HOS-ADL: 59.0-76.4 vs 75.4-97.1, 4 studies; HOS-Sport: 38.1-55.1 vs 60.9-93.9, 3 studies; iHOT-12: 43.4 vs 89.8, 1 study; VAS Pain: 6.18-6.22 vs 1.82-3.44, 2 studies; VAS Satisfaction: 7.74-8.22 range at follow up, 2 studies). Minimal clinically important difference threshold rates achieved in the hip-spine (44.1-86.7, 4 studies) cohorts were significantly lower than control (79.4-88.2%; 4 studies) cohorts in 3 studies. Patient-acceptable symptomatic state threshold rates achieved in the hip-spine (42-63.5, 3 studies) cohorts were significantly lower than control (58.8-81.0, 3 studies) in 1 study. There was no statistical difference in complication and reoperation rates between cohorts CONCLUSION: FAIS patients with concomitant HSS have improved but inferior outcomes after hip arthroscopy compared to patients without HSS LEVEL OF EVIDENCE: IV, systematic review.