Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial

Simultaneous Versus Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement: Minimum 2-Year Outcomes With a Unilateral Control Group

BACKGROUND

One-fifth of patients with femoroacetabular impingement (FAI) have bilateral symptoms. Performing bilateral hip arthroscopy on the same day minimizes the overall rehabilitation period compared with staged bilateral surgery, but most studies of outcomes from simultaneous surgery are in small cohorts.

PURPOSE/HYPOTHESIS

The purpose was to compare clinical outcome and revision rates between patients undergoing simultaneous bilateral, staged bilateral, and unilateral arthroscopic surgery for FAI from a large single-surgeon cohort. It was hypothesized that there would be no between-group differences.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Simultaneous bilateral, staged bilateral, and unilateral primary hip arthroscopy procedures between June 2005 and December 2020 were identified. Patient-reported outcome measures including the 12-item International Hip Outcome Tool (iHOT-12) score, Non-Arthritic Hip (NAH) score, and Hip Disability and Osteoarthritis Outcome Score (HOOS) were collected preoperatively and at regular intervals postoperatively. Two-year follow-up scores were analyzed if they were available, or later follow-ups if they were not. Subsequent surgery rates were recorded utilizing a compulsory national joint replacement registry.

RESULTS

A total of 196 patients (392 hips) in the simultaneous bilateral and 111 patients (222 hips) in the staged bilateral groups were compared with 1529 patients in the unilateral group. The median duration between staged surgeries was 62 days (range, 14-350 days), and demographic characteristics were similar for those having simultaneous and staged procedures. Two-year minimum postoperative scores in all 3 groups were significantly improved from preoperative scores (P < .001). Improvements were similar between groups for all scores apart from HOOS-Sports (P = .03) and HOOS-Quality of Life (P = .03), which improved less in the staged compared with the other 2 groups, and for HOOS-Quality of Life only, which attained a lower follow-up score for staged (mean, 63.1 ± 24.7) compared with simultaneous (mean, 69.8 ± 22.7) procedures (P = .04 for post hoc pairwise comparison). For the iHOT-12 score (P = .04), HOOS-Sports (P = .02), and HOOS-QoL (P = .02), a lower proportion of patients receiving staged compared with other procedures achieved minimally important clinical differences. No differences between groups in revision or arthroplasty conversion rates adjusted for follow-up time were observed.

CONCLUSION

Patients undergoing simultaneous bilateral arthroscopy for FAI achieved similar 2-year follow-up outcomes compared with staged and unilateral arthroscopy and performed better than the staged group in Sports and Quality of Life subscales of the HOOS.

Preoperative Hip Injection Response Does Not Reliably Predict 2-Year Postoperative Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

To determine whether response to preoperative local anesthetic or corticosteroid intra-articular injections can predict 2-year postoperative outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

We performed a retrospective analysis of patients undergoing hip arthroscopy for FAIS at a single institution from 2014 to 2020. Patients who underwent preoperative intra-articular hip injections were classified based on injection type (local anesthetic or corticosteroid) and whether they experienced pain relief after injection (responders or nonresponders). Responders were matched 2:1 to nonresponders by age, body mass index, and sex. Patient-reported outcomes (PROs) including the Hip Disability and Osteoarthritis Outcome Score (HOOS), 12-Item Short-Form Health Survey (SF-12) Mental Component Summary score, SF-12 Physical Component Summary score, and visual analog scale pain score were collected preoperatively and 2 years postoperatively. Mean score change and minimal clinically important difference (MCID) achievement were calculated and compared between groups.

RESULTS

The matched cohort included 126 total patients (42 nonresponders and 84 responders; 74.6% female sex; age [mean ± standard deviation], 30.9 ± 9.9 years; body mass index, 24.7 ± 3.7) with no differences in demographic or radiographic hip variables. Both groups showed significant 2-year postoperative score improvements across all PROs, except the SF-12 Mental Component Summary score, which remained unchanged. There was no difference in mean score change or MCID achievement across all PROs between the corticosteroid injection responder and nonresponder groups. In the local anesthetic group, MCID achievement was similar across all PROs, except the visual analog scale pain score, which showed a greater percentage of MCID achievement among local anesthetic nonresponders (89.5%) than in responders (55.0%, P = .03). Significant ceiling effects were most readily apparent within the injection responder group, with greater percentages of patients achieving maximal 2-year postoperative survey scores (HOOS-Activities of Daily Living, 36.9%; HOOS-Pain, 19.0%; HOOS-Quality of Life, 15.5%; and HOOS-Sport, 32.1%).

CONCLUSIONS

Response to preoperative injection with either corticosteroid or local anesthetic did not predict 2-year outcomes after hip arthroscopy in patients with FAIS.

LEVEL OF EVIDENCE

Level III, retrospective matched-cohort study.

Comparative outcomes of hip arthroscopy for femoroacetabular impingement in football and non-football athletes: a clinical analysis

INTRODUCTION

Femoroacetabular impingement (FAI) is a common cause of hip pain and dysfunction, particularly among athletes, including football players. The condition is characterized by abnormal contact between the femoral head-neck junction and the acetabulum, leading to cartilage damage and labral tears. Hip arthroscopy has emerged as a minimally invasive treatment option, offering faster recovery and improved outcomes compared to traditional surgery. This study aims to compare outcomes between football players and non-football athletes undergoing hip arthroscopy for FAI.

MATERIALS AND METHODS

This retrospective, single-center study analyzed a database of patients undergoing hip arthroscopy for FAI between 2007 and 2023. The study compared football players (n = 16) and non-football athletes (n = 16), matched for age, sex, and BMI. Pre-operative assessment included the Hip Outcome Score (HOS), Visual Analog Scale (VAS), and other functional questionnaires. Radiographic evaluations included the alpha and Wiberg angles, and intra-operative findings were recorded. The surgical approach involved femoral and acetabular osteoplasty, labral repair, or labrectomy, depending on injury morphology.

RESULTS

Both groups showed similar pre-operative pain levels (VAS) and functional scores. However, significant differences were observed in the Tegner and Hip Sports Activity Scores (HSAS), with football players showing higher activity levels pre-operatively. Both groups demonstrated significant improvements in alpha and Wiberg angles post-surgery (p < 0.001). The surgery duration was similar between groups, and no significant differences in post-operative outcomes were found between football and non-football players.

CONCLUSIONS

Hip arthroscopy is effective for both football and non-football players with FAI, with both groups experiencing significant improvements in hip joint function and pain relief. While pre-operative functional scores differed, particularly in activity levels, both groups benefited from similar post-operative outcomes, suggesting that the surgical approach is suitable for active individuals across different sports. Further research is needed to explore long-term outcomes and return-to-sport rates in these populations.

Conservative treatment versus hip arthroscopy in patients with femoroacetabular impingement : a multilevel meta-analysis of randomized controlled trials

Aims

Femoroacetabular impingement (FAI) is a serious cause of hip pain with loss of function, and development of osteoarthritis of the hip. The aim of this multilevel meta-analysis of randomized controlled trials (RCTs) was to evaluate the outcomes of FAI patients treated conservatively compared with those treated with hip arthroscopy (HAS).

Methods

A systematic literature search of PubMed, CENTRAL of the Cochrane Library, Epistemonikos, and Embase databases was conducted up to 30 June 2024. In a frequentist multilevel meta-analysis with random effects model, means with 95% CIs were calculated separately in the conservative treatment subgroup and the HAS subgroup. A test for subgroup differences in meta-analysis was then performed to determine whether there was a statistically significant difference between the means of the two subgroups. Clinical assessment was based on Harris Hip Score (HHS), the International Hip Outcome Tool (iHOT), the Hip disability and Osteoarthritis Outcome Score (HOOS), the Hip Outcome Score Activities of Daily Living (HOS-ADL), and visual analogue scale (VAS) for pain.

Results

A total of 21 RCTs, including 674 patients in the conservative treatment subgroup and 1,125 patients in the HAS subgroup, met the inclusion criteria. The test for subgroup differences showed that the HAS subgroup had a statistically significant 6.5-point higher HHS ≤ 12 months post-intervention (F = 12.8; df = 1.5; p = 0.016) and a statistically significant 9.8-point higher iHOT ≤ 24 months post-intervention (F = 5.3; df = 1.1; p = 0.035) than the conservative treatment subgroup. Other functional (HOOS, HOS) and pain (VAS, NRS) outcome parameters analyzed did not show statistically significant differences.

Conclusion

This multilevel meta-analysis of 21 RCTs with a total of 1,799 FAI patients showed a statistically significant higher HHS ≤ 12 months post-intervention and iHOT ≤ 24 months post-intervention, favouring the HAS subgroup compared to the conservative treatment subgroup, without reaching minimal clinically important differences (MCIDs).

Femoroacetabular Impingement: Critical Analysis Review of Current Nonoperative Treatments

» Femoroacetabular impingement (FAI) is the premature contact of the femoral head-neck junction with the superior acetabular rim during hip range of motion, which may further damage intra-articular soft tissue structures and lead to the accelerated development of osteoarthritis.» FAI syndrome is diagnosed by a triad of symptoms, clinical signs, and imaging findings, and is a common cause of hip pain in young patients that have a significant impact on patient hip-related function and quality of life.» The treatment of FAI syndrome begins with noninvasive nonoperative modalities such as patient education and supervised exercise-based physical therapy. For recalcitrant symptoms, various injections have been explored for both diagnostic and therapeutic purposes; however, the efficacy of these interventions have generally not been demonstrated outside of the short term» In this article, we examine the available literature regarding the nonoperative treatment of FAI and provide insight into the effectiveness of current treatment modalities.

Editorial Commentary: The Hip "Windshield Wiper Sign": An Osteochondral Defect of the Anterolateral Femoral Head, Predicts Instability and Allows Planning of Combined Arthroscopic Cartilage Therapy and Periacetabular Osteotomy

The new radiographic "windshield wiper sign" detects hip instability and an instability-related osteochondral defect of the anterolateral femoral head. It is visible on plain radiographs as well as on magnetic resonance imaging and during arthroscopy, in hips otherwise considered normal or borderline based on the lateral center-edge angle. In the past 2 decades, femoral acetabular impingement syndrome with labral lesions and cartilage lesions have been treated with excellent results. Recently the focus has shifted to complex cases, revision surgery, and capsular management preventing postoperative hip instability. Microinstability of the hip causes poor outcomes, but preoperatively, there has been no gold standard for radiographic assessment of hip instability. On plain radiographs, we use the lateral center-edge angle and the anterior center-edge angle, and we can also use the Femoro-Epiphyseal Acetabular Roof Index and the gothic arch angle. These signs help detect cases in which arthroscopic surgery alone would provide poor results and a concurrent osteotomy (e.g., a periacetabular osteotomy) is needed. We now understand that hip instability in hips otherwise considered normal or borderline dysplastic can be detected by the windshield wiper sign. This is important knowledge for concomitant arthroscopic combined with osteotomy because the need for cartilage therapy can be determined preoperatively.

Efficacy and safety of arthroscopy in femoroacetabular impingement syndrome: a systematic review and meta-analysis of randomized clinical trials

This study aimed to compare the efficacy and safety of arthroscopy with physiotherapy or joint lavage in patients with femoroacetabular impingement (FAI). A meta-analysis using PubMed, Embase, Scopus, and the Cochrane Collaboration Library databases was performed in September 2022. We included studies focusing on patients with FAI who underwent arthroscopic surgery versus those who underwent physiotherapy or arthroscopic lavage. The outcomes were functional scores (iHOT-33 and HOS ADL) and adverse events. Randomized clinical trials were included in the study. The risk of bias in each study was assessed according to Cochrane guidelines for clinical trials. The data were combined using Review Manager version 5.4. (PROSPERO CRD42022375273). Six RCTs were included, from a pool of 839 patients (407 females). There were no significant differences between groups at 6 months regarding iHOT-33 (MD 4.68, 95% CI -0.07 to 9.44) and HOS ADL (MD 5.09, 95% CI -0.07 to 10.24). The iHOT-33 and HOS ADL scales showed significant differences at 12 months in favor of the arthroscopy group (MD 10.65, 95% CI 6.54 to 14.76) and (MD 8.06, 95% CI 1.05 to 15.07). MCID was not achieved through arthroscopy in functional variables. The rate of numbness was significantly higher in the arthroscopy group. Although the arthroscopy group demonstrated statistical superiority, the clinical significance based on the MCID remains controversial, and arthroscopy did not demonstrate clinical superiority.

Clinical assessment and treatment of patients presenting with longstanding hip and groin pain in primary care: a survey study among physical therapists and general practitioners in Sweden

BACKGROUND

Methods of assessment, treatment and referral rates of patients presenting with longstanding hip and groin pain (LHGP) are not well documented. The aim of this study was to investigate assessment and treatment of patients with LHGP among general practitioners (GPs) and physical therapists (PTs) in primary care.

METHODS

An anonymous web-based survey was developed specifically for this study and distributed to GPs and PTs at primary care centers in the southern part of Sweden. The survey covered the use of different methods of assessment and treatment for LHGP, the perceived importance these methods, and referral rates to orthopedic care. Responses from clinicians were reported in frequencies and percentages, and differences in assessment methodology between professions were examined with chi-square tests.

RESULTS

PTs (n = 104) and GPs (n = 62) referred less than 25% of patients with LHGP to orthopedic care. Both professions used clinical assessments as range of motion tests, but PTs were more likely to use specific clinical tests (PTs 76% vs. GPs 19%, p = < 0.001), GPs used more imaging (GPs 98% vs. PTs 58%, p = < 0.001) and neither profession used validated patient-reported outcome measures (GPs 2% vs. PTs 11%, p = 0.134). GPs and PTs ranked patient history and range of motion as the most important factors for diagnosis. GPs and PTs both reported providing patient education and advice on physical activity as part of the treatment. GPs commonly prescribed pain medication, including NSAIDs (97%), paracetamol (100%), and opioids (69%). 77% of PTs reported treatment duration less than 3 months, with treatment consisting of combinations of exercise therapy and manual therapy.

CONCLUSIONS

GPs and PTs in primary care referred 25% or less of patients with LHGP to orthopedic care. Both professions generally used assessment for LHGP in line with clinical recommendations. However, some assessment methods differed between GPs and PTs, and neither used validated patient-reported outcome measures. Treatment strategies mainly included pain medication (GPs), exercise and manual therapy (PTs), and education (both professions). Inconsistent with clinical recommendations, GPs commonly prescribed opioids as part of pain management, and PTs report treatment duration of less than 3 months.

CLINICAL TRIAL NUMBER

NA.

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.

Patients Requiring Revision Surgery After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Show a Small Reduction of Postoperative Labral Size: A Propensity-Matched Controlled Study

PURPOSE

To compare the changes in labral size after primary hip arthroscopy between patients requiring revision surgery and those did not.

METHODS

Data collected between August 2016 and September 2021 were retrospectively reviewed. Patients diagnosed with femoroacetabular impingement syndrome and undergoing primary and revision hip arthroscopy at our institute were included in the revision group. Exclusion criteria were Tönnis grade >1, concomitant hip conditions, and incomplete magnetic resonance imaging (MRI) data. Patients who did not undergo revision surgery or conversion to total hip arthroplasty at minimum 2-year follow-up were matched in a 1:2 ratio and included in the control group. The labral size (width and height at 11:30, 1:30, and 3:00) on MRI (noncontrast, 3.0 T) before and after 12 months of primary surgery was compared.

RESULTS

Twenty-one patients were included in the revision group, and 42 patients were matched in the control group. In the revision group, significant reduction in labral width and height at 11:30 and 1:30, and labral width at 3:00 was observed at 12 months after primary hip arthroscopy (all with P < .05), whereas the control group did not show significant difference of changes in labral size (all with P > .05). Smaller postoperative labral width at 1:30 and 3:00 was observed in the revision group compared with the control group (all with P < .05). The revision group presented with greater reduction of labral width at all 3 positions and labral height at 1:30 compared with the control group (all with P < .05).

CONCLUSIONS

Patients requiring revision surgery after primary hip arthroscopy for femoroacetabular impingement syndrome presented with smaller postoperative labral size (less than 1 mm difference) and greater reduction of labral size (at or less than 1mm difference) on MRI 12 months after primary surgery compared with those patients that did not require later revision surgery.

LEVEL OF EVIDENCE

Level III, retrospective case control.

Sex-Based Differences in the Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: 10-Year Outcomes With a Nested Propensity-Matched Comparison

BACKGROUND

Sex has been associated with different pathologic characteristics in painful hips undergoing hip arthroscopic surgery.

PURPOSE

To compare minimum 10-year patient-reported outcomes (PROs) and survivorship in patients who underwent primary hip arthroscopic surgery for femoroacetabular impingement syndrome and labral tears according to sex.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from patients who underwent primary hip arthroscopic surgery between March 2009 and May 2011 were reviewed. Patients with minimum 10-year PROs for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were eligible. Exclusion criteria included previous ipsilateral hip conditions or surgical procedures, Tönnis grade >1, or dysplasia (lateral center-edge angle <25°). In the subanalysis, female patients were matched to male patients using a 1:1 ratio by age, sex, and body mass index.

RESULTS

A total of 375 hips had a minimum 10-year follow-up. There were 249 female (mean age, 36.8 ± 13.1 years) and 126 male (mean age, 38.9 ± 13.1 years) hips. Survivorship was defined as no conversion to total hip arthroplasty. Female and male hips exhibited similarly high rates of survivorship (80.3% vs 72.2%, respectively; P = .076). Female hips underwent secondary arthroscopic surgery at a statistically higher rate of 14.5% (P = .021) and had higher rates of capsular repair and iliopsoas fractional lengthening (P < .0001 and P < .001, respectively). Male hips had a significantly higher rate of acetabular labrum articular disruption/Outerbridge grade 3 and 4 damage at 54.0% compared with female hips (both P < .001) and underwent femoroplasty and acetabular microfracture at significantly higher rates of 88.1% versus 51.0%, respectively, and 16.7% versus 4.8%, respectively (both P < .001). In the subanalysis, both groups showed significant improvements in all PROs from baseline (all P < .001). Even though female patients demonstrated a higher rate of secondary arthroscopic surgery, they had a higher self-reported mean satisfaction score of 9.0 compared with 8.4 (P = .003) and a greater magnitude of improvement in 10-year PROs (ΔmHHS: 29.3 ± 17.5 vs 23.1 ± 19.8, respectively [P = .036]; ΔNAHS: 33.2 ± 21.3 vs 25.1 ± 19.5, respectively [P = .012]; ΔHOS-SSS: 47.0 ± 32.0 vs 32.7 ± 31.9, respectively [P = .008]; and ΔVAS: -4.6 ± 2.7 vs -3.5 ± 2.0, respectively [P = .009]). However, all PROs at a minimum 10-year follow-up were similar between the groups.

CONCLUSION

After undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome, both female and male patients reported significant improvements in all PROs at a minimum 10-year follow-up and high patient satisfaction, with similar final functional scores. Even though female patients demonstrated a higher rate of secondary arthroscopic surgery, they had a higher satisfaction score and a greater magnitude of improvement in PROs postoperatively.

The genetic architecture of hip shape and its role in the development of hip osteoarthritis and fracture

OBJECTIVES

Hip shape is thought to be an important causal risk factor for hip osteoarthritis and fracture. We aimed to identify genetic determinants of hip shape and use these to assess causal relationships with hip osteoarthritis.

METHODS

Statistical hip shape modelling was used to derive 10 hip shape modes (HSMs) from DXA images in UK Biobank and Shanghai Changfeng cohorts (ntotal = 43 485). Genome-wide association study meta-analyses were conducted for each HSM. Two-sample Mendelian randomisation (MR) was used to estimate causal effects between HSM and hip osteoarthritis using hip fracture as a positive control.

RESULTS

Analysis of the first 10 HSMs identified 203 independent association signals (P < 5 × 10-9). Hip shape SNPs were also associated (P < 2.5 × 10-4) with hip osteoarthritis (n = 26) and hip fracture (n = 4). Fine mapping implicated SMAD3 and PLEC as candidate genes that may be involved in the development of hip shape and hip osteoarthritis. MR analyses suggested there was no causal effect between any HSM and hip osteoarthritis, however there was evidence that HSM2 (more obtuse neck-shaft angle) and HSM4 (wider femoral neck) have a causal effect on hip fracture (ORIVW method 1.27 [95% CI 1.12-1.44], P = 1.79 × 10-4 and ORIVW 0.74 [0.65-0.84], P = 7.60 × 10-6 respectively).

CONCLUSIONS

We report the largest hip shape GWAS meta-analysis that identifies hundreds of novel loci, some of which are also associated with hip osteoarthritis and hip fracture. MR analyses suggest hip shape may not cause hip osteoarthritis but is implicated in hip fractures. Consequently, interventions targeting hip shape in older adults to prevent hip osteoarthritis may prove ineffective.

Clinical outcomes of arthroscopic surgical intervention in femoroacetabular impingement amongst the Asian population: A meta-analysis

IMPORTANCE

In Asian populations, increased prevalence of hip dysplasia as well as activities of daily living which require increased hip range of motion, such as squatting, may impact outcomes of arthroscopic surgery for femoroacetabular impingement (FAI) when compared to their Western counterparts. Existing literature lacks a comprehensive review and synthesis of knowledge focusing on outcomes of arthroscopic intervention for FAI in the Asian population.

OBJECTIVE

To conduct the first systematic review and meta-analysis that examines outcomes of arthroscopic intervention in Asian patients with FAI.

EVIDENCE REVIEW

PubMed, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane Library databases were reviewed. Case series or cohort studies assessing outcomes of arthroscopic intervention in FAI were included. Pooled analysis of modified Harris Hip Score (mHHS), Visual Analogue Scale (VAS), and adverse events were conducted. Rate of revision surgery and conversion to total hip arthroplasty (THA) were analysed as well.

FINDINGS

Six studies (5 case series, 1 cohort study) of high methodological quality involving 498 patients were included. Age of patients ranged from 20s to 70s, with a balanced gender ratio. Pooled patient-reported outcomes improved significantly postoperatively. VAS at the last follow-up mark improved by -4.28 (95 ​% CI, -4.49 to -4.08, P ​< ​0.00001), and VAS at the 12-month post-operation mark improved by -4.11 (95 ​% CI, -4.34 to -3.88, P ​< ​0.00001). The mHHS at the last follow-up mark improved by 23.37 (95 ​% CI, 20.29-26.45, P ​< ​0.00001). Revision surgery rate was low at 2.8 ​% and conversion to THA rate was 0.3 ​%.

CONCLUSIONS AND RELEVANCE

Arthroscopic intervention in FAI provides favorable outcomes in the Asian population that is comparable with outcomes seen in the Western population.

LEVEL OF EVIDENCE

Meta-analysis; Level of evidence, IV.

The Continuous Fragility Index of Statistically Significant Findings in Studies Based on High Levels of Evidence Comparing Interventions for Femoroacetabular Impingement Syndrome

BACKGROUND

Critical analysis of studies with high level of evidence has relied on the significance set by the reported P values. However, this strategy steers readers toward categorical interpretation of the data; therefore, a more comprehensive approach of data analysis is warranted. The continuous fragility index (CFI) allows for frailty interpretation of any given study's continuous outcome results.

PURPOSE

To calculate the CFI of high-level quality studies reporting significant continuous outcomes on comparison of treatment modalities for management of femoroacetabular impingement syndrome.

STUDY DESIGN

Meta-analysis; Level of evidence, 2.

METHODS

Three databases (PubMed, Embase, Cochrane) were queried from inception to February 2024 utilizing Boolean operators to combine variations of the following search terms: "femoroacetabular impingement, randomized controlled trials or prospective cohort." Studies were included if level of evidence 1 or 2, and a statistically significant outcome was reported for any continuous outcome. CFI calculation was performed for all significant outcomes to obtain a study-specific mean CFI and also for the primary outcome of each study. Mean CFI was also calculated for outcomes reported to be significant in >3 studies. Additionally, multivariable linear regression was utilized for assessment of variables associated with achievement of a higher CFI.

RESULTS

Thirteen studies totaling 1316 patients were included for analysis: 11 level of evidence 1 and 2 level of evidence 2 studies. A total of 48 outcomes reaching significance were extracted, with 8 representing primary outcomes. Study-specific mean (SD) CFI was 8 (9.3), whereas primary outcome mean CFI was 12.5 (12). In 4 of the 13 studies, the number of hips lost to follow-up was greater than the study CFI. Outcome-specific mean CFI was obtained for 5 outcomes reported in >3 studies. Multivariable linear regression revealed that larger sample size and greater journal impact factor had a significant positive association with a higher overall CFI value (P < .05).

CONCLUSION

The mean (SD) number of patient outcome events needed to reverse the significance of a continuous outcome (ie, CFI) was 8.0 (9.3). Nearly one-third of studies had a CFI less than the reported loss to follow-up, reflecting the need for better patient compliance to attain less fragile statistical results. Larger sample size and greater journal impact factor were both predictive of a higher CFI.

Medium-term results of arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of femoroacetabular impingement syndrome: a multi-centre randomised controlled trial

OBJECTIVE

To report a 3-year follow-up from the FemoroAcetabular Impingement Trial, comparing arthroscopic surgery with physiotherapy in the management of femoroacetabular impingement (FAI) syndrome for the dual primary outcomes of radiographic hip osteoarthritis (OA) and patient-reported outcome measures of activities of daily living.

METHODS

Two-group parallel, assessor-blinded, pragmatic randomised controlled trial across seven sites. 222 participants aged 18-60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n=112) or physiotherapy (n=110). Dual primary outcome measure was minimum joint space width (mJSW) on anteroposterior radiograph at 38 months post-randomisation and Hip Outcome Score ADL (HOS ADL) (higher score indicates superior outcomes). Secondary outcome measures were Scoring Hip Osteoarthritis with MRI (SHOMRI) (lower score indicates less pathology).

RESULTS

mJSW, HOS ADL and MRI data were available for 45%, 77% and 62% of participants at 38 months, respectively. No significant difference in mJSW was seen between groups at 38 months. HOS ADL was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), difference 8.9 (95% CI 7.0, 10.8)). SHOMRI score total at 38 months was lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared with the physiotherapy group (22.76 (15.26)), differences (95% CIs) -15.94 (-18.69, -13.19).

CONCLUSIONS

No difference was seen between groups on radiographic measures of OA progression. Patients with FAI syndrome treated surgically may experience superior pain and function outcomes, and less MRI-measured cartilage damage compared with physiotherapy.

TRIAL REGISTRATION NUMBER

NCT01893034.

Evaluation of Outcomes Following Arthroscopic Treatment of Femoroacetabular Impingement Syndrome Across Different Surgeons, Surgical Techniques, and Postoperative Protocols: A Multi-institutional Study

Background

Femoroacetabular impingement syndrome (FAIS) is frequently treated arthroscopically with osteoplasty and labral repair. Surgical preferences vary in terms of equipment, technique, and postoperative protocol. Patient-reported outcome measures (PROMs) are valuable tools to assess outcomes across different institutions.

Purpose

To compare PROMs after FAIS arthroscopy and evaluate the impact on postoperative outcomes with independent surgeons utilizing different surgical techniques and postoperative protocols.

Study Design

Cohort study; Level of evidence, 2.

Methods

Prospective data were collected from patients with a 2-year follow-up after arthroscopic FAIS treatment by 2 orthopaedic surgeons from different states, each attending different sports medicine fellowships. Patients were matched according to age, sex, and body mass index. Data included patient characteristics, surgical findings, and the Hip disability and Osteoarthritis Outcome Score (HOOS) preoperatively and 2 years postoperatively. Patients with revision surgery, concomitant procedures, or incomplete pre- and postoperative data were excluded. Surgeon A utilized interportal capsulotomy, capsular repair, all-suture anchors, and a postoperative hip brace. Surgeon B employed periportal capsulotomy without repair, polyether ether ketone suture anchors, and no brace. The 2 high-volume arthroscopists (>100 hips/year) performed osteoplasty and labral repair and used a large perineal post. Cohorts were analyzed with appropriate t tests, with significance set at P < .05. The percentage of patients achieving minimal clinically important difference (MCID) was calculated using Pearson chi-square tests.

Results

A total of 176 hips (100 women, 76 men) were included, with 88 matched patients from each institution. The mean age was 33.7 years and the body mass index was 26.3 kg/m2. Both cohorts significantly improved in all 5 HOOS subscales 2 years after surgery. When comparing the mean change in PROMs and the percentage of patients achieving the MCID, differences were only observed in the HOOS-Sports subscale (cohort A: 25.3 ± 29.7 vs cohort B: 34.3 ± 29.7; P = .048; MCID achieved in 57% of patients vs 76%; P = .01).

Conclusion

This prospective cohort study on arthroscopic FAIS treatment indicates that matched patient cohorts from different institutions show similarly improved PROMs at 2 years. This study suggests consistent patient outcomes across sites despite geography, surgeon, training, surgical technique, implants, and postoperative protocol.

Strength, mobility, and functional outcomes 2.5 months after hip arthroscopy for femoroacetabular impingement syndrome: A Cross-sectional Study

OBJECTIVE

Short-term deficits after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remain poorly understood. We assessed muscle strength, hip range of motion, and functional task performance 2.5 months after surgery and analyzed their association with self-reported function.

DESIGN

Cross sectional study.

PARTICIPANTS

52 patients.

MAIN OUTCOME MEASURES

Maximal isometric strength (hip flexion with both straight and flexed hip/knee, abduction and external rotation), hip range of motion (flexion, external and internal rotation), and functional tasks (bipodal/unipodal squat, bilateral vertical jump, single-leg distance hop). Between-limb differences were analyzed using paired t-tests, and the Limb Symmetry Index (LSI) was calculated.

RESULTS

The operated hip showed lower hip flexion strength (LSI = 88.4%; ES = -0.549; p < 0.001) and reduced range of motion (LSI = 75.4-92.4%; ES = -0.479 to -1.02; all p < 0.01) compared to the non-operated hip. Functional task performance did not differ between operated and non-operated hips (all p > 0.05).

CONCLUSION

Patients showed alterations in hip flexion strength and range of motion post-surgery, but functional task performance was unaffected. Targeted assessment and intervention may be needed to improve outcomes after surgery for FAIS.

Identifying Hip Arthroscopy Trends in Turkey

Background

Hip arthroscopy (HA) procedures have continued to increase worldwide. However, no data are currently available regarding the increasing HA case volume and trends in Turkey.

Purpose

To identify trends in postoperative care habits and incidence of HA in Turkey using data from the national Health Coding Reference Server (SKRS) database.

Study Design

Cross-sectional study.

Methods

Patients who underwent HA and were recorded in the SKRS database between 2016 and 2023 were identified and retrospectively analyzed. Age, sex, institution type, geographic zone, and number of procedures were determined. The incidence of HA, overall annual case volume, chemoprophylaxis prescriptions, and postoperative care habits were also evaluated. The International Classification of Diseases, 10th Revision codes for femoral neck fracture after the index procedure and total hip arthroplasty conversion rate were analyzed. The authors utilized Poisson regression to determine the ratios of before and after periods in comparison with the same periods. Statistical analysis was performed using the statistical package SPSS software.

Results

In total, 1580 HA procedures were identified. The mean age of the included patients was 39.2 ± 11.0 years (range, 18-65 years). Throughout the research period, an 833% increase in the number of surgeries was observed, whereas the incidence increased from 0.37 to 2.86 per 100,000 cases (P = .001). A significant annual increase in incidence was noted from 2017, 2018 and 2021 compared with the respective prior year. Moreover, 56.1% of all HA cases were performed in the Marmara region, whereas 47.7% of the cases were treated in private hospitals. Femoral neck fractures were encountered in 2 (0.1%) cases throughout the study duration. Enoxaparin sodium was the most preferred chemoprophylactic drug (99.4%). The 2-year total hip arthroplasty conversion rate was 3.5%.

Conclusion

This study describes the current trends in HA across Turkey and provides a perspective on physician preferences. Notably, HA procedure counts, the ratio between HA and other orthopaedic procedures, and the incidence of HA demonstrated an increasing trend, with enormous potential for further advancement. These findings highlight the need for the creation of a national registry capable of obtaining more specific and accurate data.

Patient-Reported Outcomes Associated With "Completely Better" Status at 2 Years After Hip Arthroscopy

Background

Measures such as the Patient Acceptable Symptom State and minimum clinically important difference have been used to contextualize patient-reported outcomes (PROs). Assessment of patients' perception of being "completely better" (CB) after hip arthroscopy has not been studied.

Purposes

To (1) determine the prevalence and characteristics of patients who report being CB at 2 years after hip arthroscopy; (2) determine whether PROs measuring function, pain, and mental health are associated with CB status; and (3) determine threshold values for PROs predictive of achieving CB status.

Study Design

Case-control study; Level of evidence, 3.

Methods

Patients undergoing hip arthroscopy at a single institution from October 2015 to January 2020 were administered electronic surveys assessing sociodemographic variables and PROs at baseline and 2 years postoperatively. The CB anchor question was "Is the condition for which you underwent surgery completely better now?" Threshold values for PROs associated with achieving CB status at 2 years postoperatively were identified with 90% specificity. Variables with an area under the curve of >0.80 on a receiver operating characteristic curve were selected for multivariate analysis.

Results

Overall, 29 of 62 patients (47%) achieved CB status. There were no differences in age, sex, body mass index, race, prior hip surgery, preoperative opioid use, smoking status, or preoperative expectations between the CB and no-CB groups. The CB group had better 2-year postoperative and pre- to postoperative change values on all PROs (P < .05 for all) except for the Patient-Reported Outcomes Measurement Information System (PROMIS)-Depression and the Numeric Pain Scale (NPS) for whole-body pain. Two-year postoperative PRO thresholds for achieving CB status were determined as PROMIS-Physical Function (PF) ≥51.3 or increase in PROMIS-PF ≥12 points, PROMIS-Pain Interference ≤46.6 or decrease in PROMIS-Pain Interference ≥12.2 points, NPS for operative hip pain of ≤1.0, Musculoskeletal Outcomes Data Evaluation and Management System-expectations met ≥95.0, and Surgical Satisfaction Questionnaire (SSQ-8) ≥87.5. Multivariate analysis demonstrated that higher SSQ-8 score and greater improvement on the PROMIS-PF were independent predictors of achieving CB status.

Conclusion

Almost half of the study patients perceived being CB at 2 years after hip arthroscopy. Multiple postoperative PROs scores were associated with achieving CB status.

Neither Bone Marrow Aspirate Concentrate nor Platelet-Rich Plasma Improves Patient-Reported Outcomes After Surgical Management of Acetabular Labral Tears; However, Bone Marrow Aspirate Concentrate May Be Effective for Moderate Cartilage Damage: A Systematic Review

Purpose

To (1) systematically assess which orthobiologic agents are being used in acetabular labral repairs and (2) report all available outcomes for patients undergoing operative management for labral repairs with orthobiologic agents.

Methods

The PubMed, Embase, and Cochrane databases were queried in August 2023. Articles were included if they used an orthobiologic agent during hip arthroscopy for acetabular labral repair and reported functional outcomes. Each study was queried for demographic data, orthobiologic agent used, volume of agent used, imaging modality used to guide administration, follow-up period, and all reported outcomes. The following Boolean phrase was used to systematically search the current literature: ((Orthobiologics) OR (Platelet-rich plasma) OR (PRP) OR (Mesenchymal stem cells) OR (MSCs) OR (Hyaluronic acid) OR (Growth factors) OR (bone marrow aspirate) OR (BMAC)) AND (hip joint OR (acetabular labrum) OR (Chondrolabr∗ damage) OR (Chondrolabr∗ tear)) AND (outcome∗ OR function∗ OR PROM OR PRO OR arthr∗ OR image OR pain OR complication).

Results

Three studies met the inclusion criteria and included 201 patients who received treatment with orthobiologic agents. Of these patients, 119 (59.7%) were women, with age ranging from 35 to 49 years. Ninety-seven patients (48.3%) received bone marrow aspirate concentrate (BMAC), and 104 (51.7%) received platelet-rich plasma (PRP). Both BMAC studies showed no significant improvements compared with controls; however, a subanalysis limited to patients with moderate cartilage damage who received BMAC showed significantly improved 2-year patient-reported outcome measures (International Hip Outcome Tool 33 score, 82.5 vs 69.5; P = .03). The one PRP study did not show significant improvements compared with controls. No complications were noted after either PRP or BMAC harvesting and application in any included study.

Conclusions

Overall, BMAC and PRP do not significantly improve patient-reported outcome measures compared with controls. However, there is limited evidence that BMAC may help patients with moderate cartilage damage.

Level of Evidence

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

Interleukin-6 and Interleukin-8 Gene Expressions Differ Between Male and Female Patients at Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To identify key molecular components within the femoroacetabular impingement hip and compare the findings between male and female patients across varying age groups.

Methods

All patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) without hip dysplasia were included. During hip arthroscopy, performed at University of Wisconsin Health, loose articular cartilage, excess synovium, damaged labral tissue, and minimal adipose tissue were debrided only as needed for visualization and tissue repair purposes and collected. Tissue was processed and used for quantitative polymerase chain reaction (qPCR). Genes were selected for qPCR on the basis of their associated function in inflammation and/or extracellular matrix remodeling during the progression of osteoarthritis.

Results

A total of 91 male (M) and female (F) patients 15 to 58 years old were included in the study. qPCR results indicated that Interleukin-6 (P < .05, 95% confidence interval [CI] 0.047-0.083 F, 0.070-0.12 M) and Interleukin-8 (P = .04, 95% CI 0.059-0.10 F, 0.082-0.18 M) were significantly greater in male patients compared with female patients regardless of age, and IL6 (P = .02, 95% CI [0.026-0.070] F, [0.067-0.17] M), Interleukin-1ß (P < .01 95% CI [0.013-0.063] F, [0.073-0.25] M), and Matrix metalloproteinase-13 (P = .047, 95% CI [0.0051-0.017] F, [0.0084-0.052] M) were significantly greater in male patients younger than 20 years old compared with female patients younger than 20 years old.

Conclusions

In patients with FAIS, there are significant differences between male and female patients in the biomarkers present in the affected hip at the time of surgery. Male patients have greater levels of IL6 and IL8 and male patients younger than 20 years of age have greater levels of IL1β, IL6, and MMP13 compared with age-matched female patients.

Clinical Relevance

A better understanding of the molecular markers present during varying stages of FAIS and in patients of different ages will help characterize the pathologic process behind FAIS. This may also help define future methods of targeted treatment and prevention of disease progression.

State of the Art in Rehabilitation Strategies After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Systematic Review

Background/Objectives: Femoroacetabular impingement (FAI) is a common cause of hip pain in athletes and active individuals, often requiring hip arthroscopy followed by a structured rehabilitation program. Effective rehabilitation is crucial for optimizing surgical outcomes and facilitating a return to sport. Methods: A systematic review following PRISMA guidelines was conducted to evaluate post-operative rehabilitation protocols after hip arthroscopy for FAI. Databases searched included PubMed, Embase, and Cochrane Library up to April 2024. Inclusion criteria focused on studies documenting rehabilitation post-arthroscopy for FAI, with a final selection of 14 studies encompassing 1105 patients. Data extraction focused on rehabilitation techniques, functional outcomes, and return-to-sport rates. The risk of bias was assessed using RoB2 and ROBINS-I tools. Results: Rehabilitation protocols were categorized into four phases, emphasizing manual therapy, strengthening, stretching, aquatic exercises, and sport-specific drills. The average return-to-sport rate was 90.3%. Manual therapy and aquatic programs were critical in early recovery, while strengthening and proprioception exercises were central to later stages. Variability in protocols across studies was noted. Conclusions: Post-operative rehabilitation following hip arthroscopy for FAI is essential for recovery. A phased, individualized approach, integrating manual therapy, aquatic exercises, and sport-specific training, yields positive outcomes. However, the heterogeneity of protocols suggests the need for standardized guidelines tailored to individual patient needs and activity levels.

Outcomes and complications of hip arthroscopy for femoroacetabular impingement syndrome: A narrative review

Hip arthroscopy has emerged as the primary surgical intervention for Femoroacetabular Impingement Syndrome (FAIS), a common cause of hip pain in young adults, particularly athletes. This narrative review examines the long-term outcomes, complications, and debates surrounding arthroscopic management of FAIS. Key findings include sustained improvements in patient-reported outcomes, return to sport, and functional recovery, particularly in younger patients and those with cam-type FAIS. However, some patients may eventually require total hip arthroplasty (THA), highlighting the variability in long-term durability. Complications, though infrequent, remain a significant concern, with the most common being transient neuropathy due to prolonged traction, heterotopic ossification, and iatrogenic cartilage damage. Recent studies emphasize the importance of patient selection, with younger patients, those with capsular closure, and those without pre-existing osteoarthritis showing superior outcomes. Additionally, sex-based differences suggest females may experience higher complication rates, though they often report better functional improvements post-surgery. Areas of ongoing debate include the role of labral debridement versus repair, the optimal management of mixed-type FAIS, and the potential benefits of adjunctive procedures such as ligamentum teres debridement. Future research should focus on refining surgical techniques and identifying patient-specific factors to further optimize outcomes. Despite its complexities, hip arthroscopy remains an effective treatment for FAIS, though individualized treatment plans are crucial to addressing the unique needs of each patient. By synthesizing current evidence, this review aims to guide clinicians in optimizing FAIS management and identifying areas for future research.

Diagnostic Capability of Intra-Articular Injections for Femoroacetabular Impingement Syndrome: A Systematic Review

OBJECTIVE

To review and critically appraise available literature concerning the diagnostic capability of intra-articular injections for femoroacetabular impingement (FAI) syndrome.

DESIGN

Systematic review.

SETTING

N/A.

PARTICIPANTS

N/A.

INTERVENTIONS

N/A.

MAIN OUTCOME MEASURES

Studies assessing pain relief following intra-articular injections for the diagnosis of FAI syndrome, compared with arthroscopy as diagnostic reference standard, were considered eligible. Searches were performed across 8 databases, and the risk of bias was evaluated through the Quality Assessment of Diagnostic Accuracy Studies tool.

RESULTS

From 489 articles identified, 4 were included for analysis. Intra-articular injections were composed of anesthetic agents (such as lidocaine, bupivacaine, and ropivacaine), combined or not with corticosteroids (triamcinolone and betamethasone). All studies were judged as "at risk of bias", and a substantial heterogeneity was found considering assessment methods and pain relief thresholds for a positive response to intra-articular injections. Overall, 2 studies reported that intra-articular injections presented a high accuracy in determining the presence of FAI syndrome. However, the remaining 2 studies indicated that intra-articular injections might present restricted diagnostic capability to discriminate FAI syndrome from healthy individuals or those with other hip pathologies.

CONCLUSIONS

Based on limited evidence, the diagnostic capability of intra-articular injections for FAI syndrome cannot be supported. It remains unclear which pain relief thresholds are related to a higher diagnostic capability. The combination of anesthetics with corticosteroids should also be further explored, including multiple pain assessments for evaluation of prolonged effects.

Functional Outcomes, Complications, and Failure Rates in Workers' Compensation Patients Following Hip Arthroscopic Repair: A Systematic Review

Background

Studies on the feasibility of hip arthroscopy in workers' compensation (WC) patients have been largely inconsistent or limited by study design, necessitating the need for a systematic review.

Purpose

We sought to systematically compare clinically significant differences between WC patients and their counterparts in relation to (1) functional outcomes, (2) complications, and (3) failure rates after hip arthroscopy.

Methods

We searched MEDLINE, EMBASE, and PubMed databases for studies published between January 1996 and February 2021. In combination with "AND" or "OR" Boolean operators, the following keywords were implemented: "hip arthroscopy," "workers' compensation," "outcomes," "complications," "revision," and "failure rates." Two reviewers screened eligible studies, evaluated methodological quality, and abstracted data.

Results

In the 13 studies pooled, comprising 1874 patients, 276 (14.7%) patients received WC benefits. Twelve studies utilized functional outcomes, 2 studies assessed pain, and 3 studies evaluated satisfaction. Despite scoring lower in these measures preoperatively, WC patients demonstrated significant improvements after hip arthroscopy. Three studies linked compensation with marginally inferior functional scores, but this association was not significant at longer follow-up. Seven studies examined complication incidence, and 6 studies addressed failure rates, with all reporting no significant differences in rates of complications, secondary arthroscopies, or conversion to total hip arthroplasty.

Conclusions

The findings of this systematic review suggest that hip arthroscopy offers clinically significant benefits, regardless of WC status. Postoperative results in WC patients, including functional scores, pain, satisfaction, complications, and failure rates, were favorable, and the degree of improvement was at least comparable with their counterparts. Further studies should consider prospective study designs with larger cohorts and extended follow-up.

Trends in Cartilage Repair Techniques for Chondral Defects in the Hip in Germany: An Epidemiological Analysis from 2006 to 2022

Cartilage repair techniques for chondral defects in the hip are crucial for treating conditions like femoroacetabular impingement, developmental dysplasia, and osteonecrosis, especially in young patients to delay the progression of osteoarthritis. This study aims to present age and sex distributions and trends in hip-preserving surgeries in Germany from 2006 to 2022, analyzing 116,179 procedures using the German OPS coding system. The procedures were categorized into three groups: debridement, refixation, and regeneration. Arthroscopy was more common than arthrotomy (98,916 vs. 17,263). Males underwent more procedures than females (63,771 vs. 52,408). Debridement had a monomodal age distribution peaking at 43.42 years, while refixation and regeneration exhibited bimodal patterns. Regenerative procedures were primarily performed on younger patients (average 27.73 years). A Joinpoint analysis showed an initial increase in procedures, peaking around 2013, followed by a decline. Arthroscopic procedures peaked at approximately 9000 in 2013, whereas arthrotomies peaked at around 1200 after 2014. The decline in procedures post-2013 may reflect refined surgical indications and a shift towards outpatient settings. These findings underscore the trend towards minimally invasive, scaffold-based treatments, with regenerative techniques showing promising outcomes in younger patients. Future research should focus on prospective comparative studies and cost-benefit analyses to guide clinical decision-making.

Clinical Outcomes of the Arthroscopic Capsular Suture-Lifting Technique in the Treatment of Femoroacetabular Impingement in Patients With Borderline Developmental Dysplasia of the Hip

Background

Patients with femoroacetabular impingement (FAI) are likely to present with borderline developmental dysplasia of the hip (BDDH). Considering the prolonged risk of negative prognosis in these patients, the need for surgical management of the capsule has been emphasized. Although previous studies have advocated different techniques of capsular closure during surgery, no consensus has been achieved. Therefore, the aim of this study was to evaluate the clinical outcomes of a new arthroscopic capsular suture-lifting technique for the treatment of FAI combined with BDDH.

Hypothesis

The arthroscopic capsular suture-lifting technique would achieve better anterior stability and show better clinical outcomes compared with routine capsular closure.

Study Design

Cohort study; Level of evidence, 3.

Methods

Consecutive patients diagnosed with FAI and BDDH and who underwent hip arthroscopy in our hospital between September 1, 2017, and April 30, 2021, were evaluated. Data were collected prospectively and analyzed retrospectively. Patients were divided into 2 groups according to the capsule closure methods used: capsular suture-lifting technique (lifting group) and routine capsular closure (control group). Anteroposterior hip radiography, Dunn view radiography, and computed tomography imaging were carried out for all patients preoperatively and postoperatively. Patient-reported outcomes, including the modified Harris Hip Score (mHHS) and visual analog scale (VAS) for pain, were collected preoperatively and at least 1 year after surgery and compared between the 2 groups. The Wilcoxon signed-rank test was used to evaluate changes in preoperative to postoperative mHHS scores and VAS. Mann-Whitney U test was used to evaluate significant differences in postoperative mHHS and VAS scores in the 2 groups.

Results

In all, 144 patients were included in this study, of whom 77 (53.5%) underwent the arthroscopic capsular suture-lifting technique and 67 (46.5%) underwent routine arthroscopic surgery. The patients in both groups had significant improvement in postoperative mHHS and VAS compared with the preoperative assessment (P < .05). The postoperative VAS score of patients in the suture-lifting group was significantly lower (2.6 vs 3.8; P < .05) and the mHHS score was significantly higher (75.2 vs 68.5; P < .05) than those of patients in the control group. Of the 77 patients in the suture-lifting group, 68 (88.3%) surpassed the minimal clinically important difference (MCID) and 49 (63.6%) achieved the Patient Acceptable Symptom State (PASS). Of the 67 patients in the control group, 26 (38.8%) surpassed MCID and 32 (47.8%) achieved PASS. The percentage of patients achieving MCID and PASS in the suture-lifting group was significantly greater than that in the control group (P = .007 for MCID; P = .03 for PASS).

Conclusion

The study demonstrated that the arthroscopic capsular suture-lifting technique provided good clinical outcomes in the treatment of patients with FAI combined with BDDH. This technique showed better improvement of postoperative clinical outcomes than routine capsular closure.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in High-Level Athletes: A 10-Year Follow-up

Background

Arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) has previously been reported to have favorable short-term results in high-level athletes. Less is known about long-term outcomes.

Purpose

To report outcomes 10 years after hip arthroscopy for FAIS in high-level athletes using validated patient-reported outcome measures (PROMs).

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent hip arthroscopy between November 2011 and January 2013 were included in a local hip arthroscopy registry and completed preoperative PROMs. At 10-year follow-up, the same PROMs were completed. Inclusion criteria were age <40 years at time of surgery, no prior hip surgeries, and a pre-symptomatic Hip Sports Activity Scale (HSAS) level of 7 or 8. The exclusion criterion was total hip arthroplasty at follow-up. The PROMs included the international Hip Outcome Tool-12 items (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), visual analog scale (VAS) for overall hip function, European Quality of Life-5 Dimensions questionnaire (EQ-5D) and European Quality of Life-visual analog scale (EQ-VAS), HSAS, and a single question on patient satisfaction. The rates of patients achieving minimal important change and reporting Patient Acceptable Symptom State (PASS) were reported for HAGOS and iHOT-12. For iHOT-12, preoperative results were compared with 1, 5, and 10-year follow-ups.

Results

A total of 45 patients (34 men, 11 women; 70 hips; mean age 24.4 years at time of surgery) were included, with 77 patients eligible for inclusion. Significant improvements (P < .001) were seen at 10-year follow-up in all HAGOS subscales: Symptoms, Pain, Daily Activity, Sports, Physical Activity, Quality of Life (50.3 vs 78.6, 59.2 vs 86.8, 65.9 vs 88.8, 37.1 vs 81.1, 24.4 vs 81.1, 32.1 vs 79.3), iHOT-12 (40.1 vs 81.6), EQ-5D (0.59 vs 0.89), EQ-VAS (65.6 vs 80.4), and VAS for overall hip function (48 vs 79). For iHOT-12, the largest change was seen between preoperative and 1-year follow-up values, with consistent results over time. There was no statistically significant difference between HSAS levels preoperatively and at 10-year follow-up (HSAS level 4), with 24% of patients reporting a HSAS level 7 or 8 at the follow-up. Of the patients, 93% reported satisfaction with the surgery. PASS was achieved in 82% for iHOT-12, with a range of 76% to 91% for HAGOS subscales. Furthermore, 93% exceeded the minimal important change for iHOT-12, and a range of 67% to 84% for HAGOS.

Conclusion

In a high-level athletic population, significant improvements in long-term outcomes are reported after hip arthroscopy for FAIS, with patients reporting a high satisfaction rate. The results also show that the largest improvement occurs within the first postoperative year, with results being maintained for 10 years.

Arthroscopic Pincer Resection Utilizing an Outside-In Approach for Intra-articular Access

In the standard approach to hip arthroscopy, access to the joint is achieved using fluoroscopic guidance to enter the central compartment of the hip using the Seldinger technique, penetrating the capsule with a needle and subsequently cannulating and obtaining direct visualization of the joint. In such a way, arthroscopists then proceed with accessory portal creation and capsulotomy, as desired, under direct intra-articular visualization. In cases with severe pincer morphology or coxa profunda, it may not be possible to safely access the central compartment under fluoroscopic guidance due to significant lateral overcoverage of the femoral head. We present an outside-in arthroscopic approach for accessing the hip joint in such patients, allowing for safe visualization, osseous pincer resection, and improved central compartment access while minimizing the risk to cartilage and labral tissue.

Feasibility of interdisciplinary evaluation in non-arthritic hip pain: A randomized trial

BACKGROUND

Physical therapy and orthopaedic surgery are two common treatments for non-arthritic hip pain. Interdisciplinary evaluation across these disciplines may produce a more supportive treatment-planning process; however, the feasibility of such an evaluation remains unknown.

HYPOTHESIS OBJECTIVE

To assess the feasibility of an interdisciplinary evaluation with an orthopaedic surgeon and physical therapist for non-arthritic hip pain.

STUDY DESIGN

Observational feasibility study of a randomized controlled trial.

METHODS

Participants were randomized to an interdisciplinary (surgeon + physical therapist) or standard (surgeon) evaluation in a hip preservation clinic. Recruitment rate was recorded. Retention rate was calculated for all variables of interest. Enrollment and refusal reasons were recorded as patient quotes and categorized by a single grader. Time spent in clinic was compared across groups using Mann Whitney U tests (P ≤ 0.05). Study clinicians were interviewed, and responses were categorized based on pre-determined themes.

RESULTS

Eighty-one percent of eligible patients enrolled over a 15-month recruitment period. Willingness(n = 16), urgency to resolve pain(n = 10), financial compensation(n = 1), interest in research(n = 42), physical therapy(n = 6), or multiple-provider care(n = 15) were participants' enrollment reasons; reason was not recorded for 22 participants. Time(n = 11), preference for single-provider care(n = 6), current physical therapy treatment(n = 1), and disinterest in physical therapy(n = 7) or research(n = 2) were refusal reasons of patients who did not enroll. Retention for primary variables of interest was 100% in both groups. Participants spent, on average, 23.5 min more time in clinic for the interdisciplinary evaluation compared to the standard (P < 0.001).

CONCLUSIONS

An interdisciplinary evaluation for patients with non-arthritic hip pain that included a physical therapist and orthopaedic surgeon in a hip preservation clinic was feasible and may better inform the treatment planning process.

Femoroacetabular impingement syndrome in middle-aged individuals is strongly associated with the development of hip osteoarthritis within 10-year follow-up: a prospective cohort study (CHECK)

OBJECTIVE

The objective is to determine the association and absolute risk of femoroacetabular impingement syndrome (FAIS) for the development of radiographic hip osteoarthritis (RHOA).

METHODS

This is a nationwide, multicentre prospective cohort study (Cohort Hip and Cohort Knee) with 1002 individuals aged between 45 and 65 years. Hips without definitive RHOA (Kellgren-Lawrence (KL) grade≤1) at baseline and with anteroposterior pelvic radiographs at baseline and 10-year follow-up available (n=1386 hips) were included. FAIS was defined by the baseline presence of a painful hip, limited internal hip rotation≤25° and cam morphology defined by an alpha angle>60°. The outcomes were incident RHOA (KL grade≥2 or total hip replacement (THR)) and incident end-stage RHOA (KL≥3 or THR) within 10 years.

RESULTS

Of the 1386 included hips (80% women; mean age 55.7±5.2 years), 21 hips fulfilled criteria for FAIS and 563 hips did not fulfil any of the FAIS criteria (reference group; no symptoms, no signs, no cam morphology). Within 10-year follow-up, 221 hips (38%) developed incident RHOA and 15 hips (3%) developed end-stage RHOA (including 9 hips with THR). Adjusted for sex, age and body mass index, FAIS with cam morphology resulted in an OR of 6.85 (95% CI 2.10 to 22.35) for incident RHOA and 47.82 (95% CI 12.51 to 182.76) for incident end-stage RHOA, compared with hips not having any FAIS criteria. The absolute risk of FAIS was 81% for incident RHOA and 33% for incident end-stage RHOA.

CONCLUSION

FAIS was strongly associated with the development of RHOA within 10 years. Although the baseline prevalence of FAIS was low, the high absolute risk of FAIS for RHOA warrants further studies to determine preventive strategies.

How to Best Identify Acetabular Retroversion on Radiographs: Thresholds to Guide Clinical Practice

BACKGROUND

Acetabular retroversion is associated with impingement and instability. An adequate interpretation of acetabular version and coverage on radiographs is essential to determine the optimal treatment strategy (periacetabular osteotomy vs hip arthroscopic surgery). The crossover sign (COS) has been associated with the presence of acetabular retroversion, and the anterior wall index (AWI) and posterior wall index (PWI) assess anteroposterior acetabular coverage. However, the radiographic appearance of the acetabulum is sensitive to anterior inferior iliac spine (AIIS) morphology and pelvic tilt (PT), which differs between the supine and standing positions.

PURPOSE

To (1) identify differences in the acetabular appearance between the supine and standing positions among patients presenting with hip pain; (2) determine factors (acetabular version, AIIS morphology, and spinopelvic characteristics) associated with the crossover ratio (COR), AWI, and PWI; and (3) define relevant clinical thresholds to guide management.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients who presented to a hip preservation surgical unit (n = 134) were included (mean age, 35 ± 8 years; 58% female; mean body mass index, 27 ± 6). All participants underwent supine and standing anteroposterior pelvic radiography to assess the COS, COR, AWI, and PWI as well as standing lateral radiography to determine standing PT. Computed tomography was used to measure supine PT, acetabular version, and AIIS morphology. Acetabular version was measured at 3 transverse levels, corresponding to the 1-, 2-, and 3-o'clock positions. The correlation between radiographic characteristics (COR, AWI, and PWI) and acetabular version, AIIS morphology, and PT was calculated using the Spearman correlation coefficient. Receiver operating characteristic curve analysis was performed to define thresholds for the COR, AWI, and PWI to identify retroversion (version thresholds: <10°, <5°, and <0°).

RESULTS

The COS was present in 55% of hips when supine and 30% when standing, with a mean difference in the COR of 12%. The supine COR (rho = -0.661) and AWI/PWI ratio (rho = -0.618) strongly correlated with acetabular version. The COS was more prevalent among patients with type 2 AIIS morphology (71%) than among those with type 1 AIIS morphology (43%) (P = .003). COR thresholds of 23% and 28% were able to identify acetabular version <5° (sensitivity = 81%; specificity = 80%) and <0° (sensitivity = 88%; specificity = 85%), respectively. An AWI/PWI ratio >0.6 was able to reliably identify acetabular version <0° (sensitivity = 83%; specificity = 84%). In the presence of a COR >30% and an AWI/PWI ratio >0.6, the specificity to detect retroversion was significantly increased (>90%).

CONCLUSIONS

The presence of the COS was very common among patients with hip pain. False-positive results (high COR/normal version) may occur because of AIIS morphology/low PT. Relevant thresholds of COR >30% and AWI/PWI ratio >0.6 can help with diagnostic accuracy. In cases in which either the COR or AWI/PWI ratio is high, axial cross-sectional imaging can further help to avoid false-positive results.

Neuropathic pain is a feature in patients with symptomatic femoral acetabular impingement

Femoral acetabular impingement syndrome (FAIS) is a cause of hip pain thought to be nociceptive, although pain phenotypes e.g., burning, pain attacks, prickling, numbness etc., are reported, mimicking neuropathic pain. Although no lesion to the somatosensory system is identified, neuropathic pain (NeP) may explain why nociceptive-focussed treatments are not always successful.

OBJECTIVE

To identify NeP in patients with FAIS and investigate if related to poorer outcomes.

DESIGN

A secondary analysis of the Femoral Acetabular Impingement Trial (FAIT). Outcome of interest: PainDETECT questionnaire; secondary outcomes of interest; International Hip Outcome Tool (iHOT33), Hospital Anxiety and Depression Scale (HADS) and VAS 'average pain over a month', at baseline and 8 months follow-up. Intervention (surgery or physiotherapy) were pooled.

RESULTS

173 data sets at baseline; 123 at 8 months follow-up. Baseline painDETECT identified three groups: 69% nociceptive, 19% unclear and 12% neuropathic pain phenotypes. Baseline, median scores were higher for the neuropathic group compared to the nociceptive group demonstrating borderline anxiety (9.5(5.3 to 14.2), 5(3 to 8), higher normal values for depression (7.5(2.3 to 11.8), (4(2 to 9), higher average pain (7 (6 to 8), 5(4 to 6) and lower iHOT33 14.2(9 to 21.1), 38.4(26.2 to 55.7). Post treatment, there was a median change in the neuropathic score in both iHOT33 (40.8 (25 to 76.5) with a median difference of 24.13 (CI 95% 10.46 to 45.92) and average pain 4.5(1.5 to 7) with a median difference of 2 (CI 95% 1 to 5) but to a lesser amount than the nociceptive group, iHOT33 (64(38.2 to 86.6) with a median difference of 15.50 (CI 95% 6.41 to 21.82) and average pain 3(1 to 5.7) with a median difference of 1 (CI 95% 0.5 to 1).

CONCLUSION

NeP exists in symptomatic FAIS patients and is associated with increased average pain, and functional limitations. Nociceptive-targeted treatment improves hip function and pain but with less improvement in the NeP group when compared to the nociceptive group. Pain phenotyping before intervention may improve outcomes. CONTRIBUTION OF PAPER.

The Otto Aufranc Award: Does Hip Arthroscopy at the Time of Periacetabular Osteotomy Improve the Clinical Outcome for the Treatment of Hip Dysplasia? A Multicenter Randomized Clinical Trial

BACKGROUND

A periacetabular osteotomy (PAO) is often sufficient to treat the symptoms and improve quality of life for symptomatic hip dysplasia. However, acetabular cartilage and labral pathologies are very commonly present, and there is a lack of evidence examining the benefits of adjunct arthroscopy to treat these. The goal of this study was to compare the clinical outcome of patients undergoing PAO with and without arthroscopy, with the primary end point being the International Hip Outcome Tool-33 at 1 year.

METHODS

In a multicenter study, 203 patients who had symptomatic hip dysplasia were randomized: 97 patients undergoing an isolated PAO (mean age 27 years [range, 16 to 44]; mean body mass index of 25.1 [range, 18.3 to 37.2]; 86% women) and 91 patients undergoing PAO who had an arthroscopy (mean age 27 years [range, 16 to 49]; mean body mass index of 25.1 [17.5 to 25.1]; 90% women).

RESULTS

At a mean follow-up of 2.3 years (range, 1 to 5), all patients exhibited improvements in their functional score, with no significant differences between PAO plus arthroscopy versus PAO alone at 12 months postsurgery on all scores: preoperative International Hip Outcome Tool-33 score of 31.2 (standard deviation [SD] 16.0) versus 36.4 (SD 15.9), and 12 months postoperative score of 72.4 (SD 23.4) versus 73.7 (SD 22.6). The preoperative Hip disability and Osteoarthritis Outcome pain score was 60.3 (SD 19.6) versus 66.1 (SD 20.0) and 12 months postoperative 88.2 (SD 15.8) versus 88.4 (SD 18.3). The mean preoperative physical health Patient-Reported Outcomes Measurement Information System score was 42.5 (SD 8.0) versus 44.2 (SD 8.8) and 12 months postoperative 48.7 (SD 8.5) versus 52.0 (SD 10.6). There were 4 patients with PAO without arthroscopy who required an arthroscopy later to resolve persistent symptoms, and 1 patient from the PAO plus arthroscopy group required an additional arthroscopy.

CONCLUSIONS

This randomized controlled trial has failed to show any significant clinical benefit in performing hip arthroscopy at the time of the PAO at 1-year follow-up. Longer follow-up will be required to determine if hip arthroscopy provides added value to a PAO for symptomatic hip dysplasia.

Femoroacetabular Impingement and Groin Injuries Among Soccer Players

Groin injuries and femoroacetabular impingement are common among soccer players and can provide a challenge in diagnosis, as well as treatment. Nonoperative and operative measures are the 2 predominant treatments. This current review investigates the recent literature on groin and femoroacetabular impingement injuries in soccer players, as well as potential treatment modalities.

Effect of the presence of cysts in the hip joint on hip arthroscopy

OBJECTIVES

The aim of this study was to investigate whether the presence and size of fibrous cysts affected postoperative results in patients undergoing hip arthroscopy.

PATIENTS AND METHODS

Between January 2010 and December 2019, a total of 261 patients (138 males, 123 females; mean age: 39.5±11.9 years; range, 18 to 66 years) who underwent hip arthroscopy with the diagnosis of cam-pincer-mixed-type femoroacetabular impingement (FAI) and labral pathologies were retrospectively analyzed. The study groups (impingements and labral pathologies) and the presence of cyst (or cyst size: <5 mm, 5-8 mm, >8 mm) were used as the fixed effects, and the analysis was adjusted for baseline age, sex, and preoperative scores. Pre- and postoperative modified Harris Hip Score (mHHS) and Visual Analog Scale (VAS) scores that were applied to all patients were used as an indication of clinical results.

RESULTS

The mean preoperative mHHS score of the patients with a cyst was significantly lower compared to the patients without a cyst (56.8±12.3 vs. 60.3±12.7, p=0.026). The mean change in the mHHS score and the mean percentage change in VAS score were significantly higher in the patients with a cyst compared to the patients without a cyst (mHHS score: 28.1±14.0 vs. 22.5±14.1, p=0.002; VAS score: 61.9±30.2 vs. 52.6±47.4, p=0.038). The increase in mHHS score over time for patients with a cyst was significantly higher than the patients without cysts in the pincer group (38.1±11.1 vs. 19.3±13.5, p<0.001). The patients with a cyst size of >8 mm had a significantly higher increase in the mHHS scores compared to the patients with a cyst size of <5 mm (29.5±12.9 vs. 23.5±13.8, p=0.043).

CONCLUSION

Subchondral cysts in the femoral head and neck junction accompanied cam-type and mixed-type FAI, while subchondral cysts in the acetabulum accompanied pincer-type impingement. In all groups, the mean increase in mHHS scores and the mean decrease in VAS scores were higher in patients with subchondral cysts than in patients without cysts. In patients with subchondral cysts, if the lesion causing FAI is treated arthroscopically, it can positively affect the functional results.

Minimal Clinically Important Difference, Substantial Clinical Benefit, and Patient Acceptable Symptom State Values After Hip Arthroscopy for Femoroacetabular Impingement Are Highly Dependent on Their Study Population and Calculation Methods: A Systematic Review

PURPOSE

To provide a summary of available literature on the minimal clinically important difference (MCID), substantial clinical benefit (SCB), and patient acceptable symptom state (PASS) after hip arthroscopy for femoroacetabular impingement (FAI).

METHODS

A systematic review was conducted via the Cochrane Library, PubMed, Ovid MEDLINE, and Embase to identify studies that calculated MCID, SCB, or PASS for patient-reported outcome measures after hip arthroscopy for FAI. The electronic search strategy used was as follows: hip AND arthroscopy AND (MCID OR "minimal clinically important difference" OR SCB OR "substantial clinical benefit" OR PASS OR "patient acceptable symptom state"). Inclusion criteria were English-language studies published from 1980 to 2023 reporting clinical outcome scores and calculated values of MCID, PASS, or SCB for patients undergoing hip arthroscopy for FAI.

RESULTS

Forty-two studies (5 Level II, 19 Level III, and 18 Level IV) met inclusion and exclusion criteria. The most commonly used outcome measures across MCID, SCB, and PASS were the Hip Outcome Score sports-specific subscale and the activities of daily living subscale, the modified Harris Hip Score, and the 12-item international Hip Outcome Tool. The range of MCID values for Hip Outcome Score sports-specific subscale, Hip Outcome Score activities of daily living subscale, modified Harris Hip Score, and 12-item international Hip Outcome Tool were 7.2-15.7, 7.3-15.4, 7.2-16.8, and 8.8-16.2 respectively. Similarly, for SCB the values ranged from 77.9-96.9, 90.4-98.5, 20.0-98.4, and 66.7-87.5, respectively. Lastly, the PASS values ranged from 63.9-80.9, 85.9-99.2, 74.0-97.0, and 59.5-86.0, respectively.

CONCLUSIONS

MCID, SCB, and PASS values for patient-reported outcome measures after hip arthroscopy for the management of FAI are highly dependent on their associated study including study population and calculation methods.

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

Variation in the Cost of Hip Arthroscopy for Labral Pathological Conditions: A Time-Driven Activity-Based Costing Analysis

BACKGROUND

Despite growing interest in delivering high-value orthopaedic care, the costs associated with hip arthroscopy remain poorly understood. By employing time-driven activity-based costing (TDABC), we aimed to characterize the cost composition of hip arthroscopy for labral pathological conditions and to identify factors that drive variation in cost.

METHODS

Using TDABC, we measured the costs of 890 outpatient hip arthroscopy procedures for labral pathological conditions across 5 surgeons at 4 surgery centers from 2015 to 2022. All patients were ≥18 years old and were treated by surgeons who each performed ≥20 surgeries during the study period. Costs were normalized to protect the confidentiality of internal hospital cost data. Descriptive analyses and multivariable linear regression were performed to identify factors underlying cost variation.

RESULTS

The study sample consisted of 515 women (57.9%) and 375 men (42.1%), with a mean age (and standard deviation) of 37.1 ± 12.7 years. Most of the procedures were performed in patients who were White (90.6%) or not Hispanic (93.4%). The normalized total cost of hip arthroscopy per procedure ranged from 43.4 to 203.7 (mean, 100 ± 24.2). Of the 3 phases of the care cycle, the intraoperative phase was identified as the largest generator of cost (>90%). On average, supply costs accounted for 48.8% of total costs, whereas labor costs accounted for 51.2%. A 2.5-fold variation between the 10th and 90th percentiles for total cost was attributed to supplies, which was greater than the 1.8-fold variation attributed to labor. Variation in total costs was most effectively explained by the labral management method (partial R 2 = 0.332), operating surgeon (partial R 2 = 0.326), osteoplasty type (partial R 2 = 0.087), and surgery center (partial R 2 = 0.086). Male gender (p < 0.001) and younger age (p = 0.032) were also associated with significantly increased costs. Finally, data trends revealed a shift toward labral preservation techniques over debridement during the study period (with the rate of such techniques increasing from 77.8% to 93.2%; P trend = 0.0039) and a strong correlation between later operative year and increased supply costs, labor costs, and operative time (p < 0.001 for each).

CONCLUSIONS

By applying TDABC to outpatient hip arthroscopy, we identified wide patient-to-patient cost variation that was most effectively explained by the method of labral management, the operating surgeon, the osteoplasty type, and the surgery center. Given current procedural coding trends, declining reimbursements, and rising health-care costs, these insights may enable stakeholders to design bundled payment structures that better align reimbursements with costs.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level IV . See Instructions for Authors for a complete description of levels of evidence.

Arthroscopic Treatment of Femoroacetabular Impingement Syndrome: An Updated Review

Treatment strategies for femoroacetabular impingement (FAI) syndrome have evolved in tandem with increased comprehension of FAI's impact on hip joint health. Early intervention, including arthroscopic surgery, has gained popularity due to its potential to delay the progression of osteoarthritis. Arthroscopic surgery has demonstrated significant efficacy in treating FAI syndrome, with robust evidence from randomized controlled trials and systematic reviews supporting its use. Despite arthroscopic surgery's success, complications and reoperations are not uncommon. The incidence ranges from 1% to 31% and 4% to 13%, respectively. Adjunctive biologic treatments, such as bone marrow aspirate concentrates and platelet-rich plasma, have shown promise in chondral lesion management. However, robust evidence supporting their routine use in FAI syndrome is currently lacking. Among conservative treatment methods, intra-articular injections offer diagnostic and therapeutic benefits for FAI patients. While they may provide pain relief and aid in prognosis, their long-term efficacy remains a subject of debate. Comparative studies between conservative and arthroscopic treatments highlight the importance of personalized approaches in managing FAI syndrome. In conclusion, recent advancements in FAI syndrome management have illuminated various treatment modalities. Arthroscopic surgery stands as a pivotal intervention, offering substantial benefits in pain relief, function, and quality of life. However, careful patient selection and postoperative monitoring are crucial for optimizing outcomes. Adjunctive biologics and intra-articular injections show promise but require further investigation. Tailoring treatment to individual patient characteristics remains paramount in optimizing FAI syndrome management.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: 24-Month Results From a Randomized Controlled Trial

BACKGROUND

The indications for hip arthroscopy in patients aged ≥40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty.

PURPOSE

To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged ≥40 years with limited radiographic osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This single-surgeon, parallel randomized controlled trial included patients aged ≥40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses.

RESULTS

A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion.

CONCLUSION

In patients ≥40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age ≥40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair.

REGISTRATION

NCT03909178 (ClinicalTrials.gov identifier).

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.

Quantifying radiation exposure in the radiological investigation of non-arthritic hip pain

Radiological investigations are essential for evaluating underlying structural abnormalities in patients presenting with non-arthritic hip pain. The aim of this study is to quantify the radiation exposure associated with common radiological investigations performed in assessing patients presenting with non-arthritic hip pain. A retrospective review of our institutional imaging database was performed. Data were obtained for antero-posterior, cross-table lateral, frog lateral radiographs and low-dose CT hip protocol. The radiation dose of each imaging technique was measured in terms of dose-area product with units of mGy cm2, and the effective doses (ED, mSv) calculated. The effective radiation dose for each individual hip radiograph performed was in the range of 0.03-0.83 mSv [mean dose-area product 126.7-156.2 mGy cm2]. The mean ED associated with the low-dose CT hip protocol (including assessment of femoral anteversion and tibial torsion) was 3.04 mSv (416.8 mGy cm2). The radiation dose associated with the use of CT imaging was significantly greater than plain radiographs (P < 0.005). Investigation of non-arthritic hip pain can lead to significant ionizing radiation exposure for patients. In our institution, the routine protocol is to obtain an antero-posterior pelvic radiograph and then a specific hip sequence Magnetic Resonance Imaging (MRI) scan which includes the assessment of femoral anteversion. This provides the necessary information in the majority of cases, with CT scanning reserved for more complex cases where we feel there is a specific indication. We would encourage the hip preservation community to carefully consider and review the use of ionizing radiation investigations.

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study

PURPOSE

To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater.

METHODS

An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%.

RESULTS

Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration.

CONCLUSIONS

There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy.

LEVEL OF EVIDENCE

Level V, expert opinion.

Predictors of Clinical Outcomes After Hip Arthroscopy: 10-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have beneficial outcomes, there is a paucity of literature examining predictive factors of 10-year clinical outcomes.

PURPOSE

(1) To identify predictive factors of 10-year outcomes of hip arthroscopy and (2) to compare these factors with those found in 2-year and 5-year studies.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had a minimum 10-year follow-up on 2 patient-reported outcome measures: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Exclusion criteria included previous ipsilateral hip conditions. Using bivariate and multivariate analyses, that authors analyzed the effects of 37 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

Of the 883 patients who met the inclusion criteria, 734 (83.1%) had follow-up data. The mean follow-up time was 124.4 months (range, 120.0-153.1 months). Six variables were significant predictors of NAHS in both multivariate and bivariate analyses: revision status, body mass index (BMI), duration of symptoms, preoperative NAHS, age at onset of symptoms, and need for acetabular microfracture. Positive predictors of 10-year survivorship included acute injury and gluteus medius repair, while negative predictors included revision arthroscopy, Tönnis grade, acetabular inclination, iliopsoas fractional lengthening, and notchplasty.

CONCLUSION

Multiple predictive factors including age, BMI, revision status, and preoperative outcome scores were identified for long-term survivorship and functional outcomes. These may prove useful to clinicians in refining indications and guiding patients on expected outcomes of hip arthroscopy.

Bibliometric analysis of the acetabular labrum

The acetabular labrum (AL) plays a crucial role in the normal physiological functioning of the hip joint. This study aims to present an overview of the current status and research hotspots concerning the AL and to explore the field from a bibliometric perspective. A total of 1918 AL-related records published between January 1, 2000 and November 8, 2023 were gathered from the Web of Science Core Collection database. By utilizing tools such as HisCite, CiteSpace, VOSviewer, and the R package "bibliometrix," the regions, institutions, journals, authors, and keywords were analyzed to predict the latest trends in AL research. Global research interest and publication output related to this topic continues to escalate. The United States leads in international collaborations, number of publications, and citation frequency, underscoring its preeminent position in this field. The American Hip Institute emerged as the most prolific institution, making the greatest contribution to publications. Notably, Arthroscopy and the American Journal of Sports Medicine are the 2 most popular journals in this domain, accounting for 13.29% and 10.1% of publications, respectively, and were also found to be the most co-cited journals. Amongst authors, Benjamin G. Domb leads with 160 articles (8.35%), while Marc J. Philippon is the most frequently cited author. The keyword co-occurrence network showed 3 hot clusters, including "AL," "femoral acetabular impingement (FAI)," and "osteoarthritis." In addition, "survivorship," "FAI," and "patient-reported outcomes" were identified as trending topics for future exploration. This study represents the first comprehensive bibliometric analysis, summarizing the present state and future trends in AL research. The findings serve as a valuable resource for scholars, offering practical insights into key information within the field and identifying potential research frontiers and emerging directions in the near future.

Squatting biomechanics following physiotherapist-led care or hip arthroscopy for femoroacetabular impingement syndrome: a secondary analysis from a randomised controlled trial

Background

Femoroacetabular impingement syndrome (FAIS) can cause hip pain and chondrolabral damage that may be managed non-operatively or surgically. Squatting motions require large degrees of hip flexion and underpin many daily and sporting tasks but may cause hip impingement and provoke pain. Differential effects of physiotherapist-led care and arthroscopy on biomechanics during squatting have not been examined previously. This study explored differences in 12-month changes in kinematics and moments during squatting between patients with FAIS treated with a physiotherapist-led intervention (Personalised Hip Therapy, PHT) and arthroscopy.

Methods

A subsample (n = 36) of participants with FAIS enrolled in a multi-centre, pragmatic, two-arm superiority randomised controlled trial underwent three-dimensional motion analysis during squatting at baseline and 12-months following random allocation to PHT (n = 17) or arthroscopy (n = 19). Changes in time-series and peak trunk, pelvis, and hip biomechanics, and squat velocity and maximum depth were explored between treatment groups.

Results

No significant differences in 12-month changes were detected between PHT and arthroscopy groups. Compared to baseline, the arthroscopy group squatted slower at follow-up (descent: mean difference -0.04 m∙s-1 (95%CI [-0.09 to 0.01]); ascent: -0.05 m∙s-1 [-0.11 to 0.01]%). No differences in squat depth were detected between or within groups. After adjusting for speed, trunk flexion was greater in both treatment groups at follow-up compared to baseline (descent: PHT 7.50° [-14.02 to -0.98]%; ascent: PHT 7.29° [-14.69 to 0.12]%, arthroscopy 16.32° [-32.95 to 0.30]%). Compared to baseline, both treatment groups exhibited reduced anterior pelvic tilt (descent: PHT 8.30° [0.21-16.39]%, arthroscopy -10.95° [-5.54 to 16.34]%; ascent: PHT -7.98° [-0.38 to 16.35]%, arthroscopy -10.82° [3.82-17.81]%), hip flexion (descent: PHT -11.86° [1.67-22.05]%, arthroscopy -16.78° [8.55-22.01]%; ascent: PHT -12.86° [1.30-24.42]%, arthroscopy -16.53° [6.72-26.35]%), and knee flexion (descent: PHT -6.62° [0.56- 12.67]%; ascent: PHT -8.24° [2.38-14.10]%, arthroscopy -8.00° [-0.02 to 16.03]%). Compared to baseline, the PHT group exhibited more plantarflexion during squat ascent at follow-up (-3.58° [-0.12 to 7.29]%). Compared to baseline, both groups exhibited lower external hip flexion moments at follow-up (descent: PHT -0.55 N∙m/BW∙HT[%] [0.05-1.05]%, arthroscopy -0.84 N∙m/BW∙HT[%] [0.06-1.61]%; ascent: PHT -0.464 N∙m/BW∙HT[%] [-0.002 to 0.93]%, arthroscopy -0.90 N∙m/BW∙HT[%] [0.13-1.67]%).

Conclusion

Exploratory data suggest at 12-months follow-up, neither PHT or hip arthroscopy are superior at eliciting changes in trunk, pelvis, or lower-limb biomechanics. Both treatments may induce changes in kinematics and moments, however the implications of these changes are unknown.

Trial registration details

Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015.

First-line treatment for femoroacetabular impingement syndrome and hip-related quality of life: study protocol for a multicentre randomised controlled trial comparing a 6-month supervised strength exercise intervention to usual care (the Better Hip Trial)

INTRODUCTION

Femoroacetabular impingement syndrome (FAIS) is a motion-related and position-related clinical condition of the hip associated with pain, reduced physical function and hip-related quality of life (QoL). Interestingly, higher maximal muscle strength is associated with less pain, better physical function and improved QoL in people with FAIS. Furthermore, preliminary evidence suggests that a proportion of patients with FAIS respond positively to strength exercise as first-line treatment. Nonetheless, there is little evidence supporting a specific exercise intervention offered as a first-line treatment. We will conduct a randomised controlled trial investigating the clinical effectiveness and cost-effectiveness of a 6-month strength exercise intervention compared with usual care as first-line treatment in patients with FAIS.

METHODS AND ANALYSIS

This is a multicentre randomised controlled trial that will be conducted at hospitals and physiotherapy clinics across Denmark and Australia. A total of 120 patients with FAIS will be randomised (1:1) to 6 months of supervised strength exercise or usual care. The primary outcome is the change in hip-related QoL measured using the International Hip and Outcome Tool 33 (iHOT-33) from baseline to the end of intervention. A health economic evaluation will be conducted from a societal and healthcare perspective based on the data collection over a 12-month period starting at baseline. The analysis will calculate incremental cost-effectiveness ratios using quality-adjusted life-years and iHOT-33 scores while estimating costs using microcosting and cost questionnaires. Secondary outcomes include objectively measured physical function at baseline and after 6 months and patient-reported outcomes measured at baseline, 3-month, 6-month and 12-month follow-up.

ETHICS AND DISSEMINATION

The trial has been approved by the Committee on Health Research Ethics in the Central Denmark Region (journal no 1-10-72-45-23) and La Trobe University Human Ethics Committee (HEC24042) and is registered at the Central Denmark Region List of Research Projects (journal no 1-16-02-115-23). Informed consent will be obtained from each participant before randomisation. Results will be published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05927935.

Femoroacetabular Impingement and the Effect of Osteochondroplasty on Hip Osteoarthritis Prevention: The Pandora's Box Opening Process

OBJECTIVE

This study was conducted to assess the effect of osteochondroplasty on osteoarthritis (OA) prevention, comparing radiological evolution between identical hips from the same patient who had undergone unilateral surgery.

DESIGN

We retrospectively reviewed radiological evolution between hips with similar shape from the same patient who had undergone unilateral surgery. In all, 56 FAI patients (112 hips) with a mean age of 42.18 ± 9.16 years and had undergone unilateral arthroscopy treatment have been included. Four independent researchers measured Wiberg, Acetabular and Alpha angles, Extrusion index, and Tönnis classification preoperatively to verify that operated and non-operated hips had the same shape. OA evolution was assessed by joint space width (JSW) in 3 different articular points and Tönnis classification.

RESULTS

No preoperative anatomical differences were present between groups (P > 0.05). At the end of follow-up (31.9 months), a decrease of JSW in the 3 points measured was found in OP hips (OP vs. N-OP; P < 0.01). These results were correlated with changes in the proportion of patients who progressed to grade III in Tönnis classification (from 1.3% preoperative to 23.2% at the end of follow-up).

CONCLUSIONS

Osteochondroplasty and labrum procedures were not associated with OA prevention. The OP hips showed a faster OA degeneration, which was not seen in the N-OP. These results will encourage hip surgeons to perform further investigations to avoid the "Pandora's Box Opening Process."

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.

Concomitant Ipsilateral Knee Pain Is Associated With Worse Preoperative Functional Status and Short-Term Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome

PURPOSE

(1) To determine the effect of concomitant ipsilateral knee pain (IKP) on short-term outcomes after hip arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) and (2) to determine whether IKP would improve with surgery.

METHODS

Data between September 2021 and May 2022 were reviewed. Patients with a diagnosis of FAIS who underwent hip arthroscopy with a minimum of 1-year follow-up were included. The exclusion criteria were prior ipsilateral hip or knee surgery, hip Tönnis grade greater than 1, knee Kellgren-Lawrence grade greater than 2, hip conditions (avascular necrosis, Legg-Calvé-Perthes disease, pigmented villonodular synovitis, osteoid osteoma, synovial chondromatosis, and developmental dysplasia of the hip), and spine diseases. All patients underwent knee magnetic resonance imaging preoperatively. Preoperative and short-term (1-year) patient-reported outcomes were collected, consisting of the Hip Sports Activity Scale score, weekly sports participation, modified Harris Hip Score (mHHS), 12-component International Hip Outcome Tool (iHOT-12) score, and visual analog pain scale (VAS) scores for the hip and the ipsilateral knee. The percentages of patients achieving the minimal clinically important difference and patient acceptable symptom state (PASS) for the mHHS and iHOT-12 score were calculated. Multivariate regression analysis was performed to determine the effect of IKP severity on postoperative outcomes. Subgroup analysis was performed between patients with IKP alleviation and those without IKP alleviation.

RESULTS

Among the 107 patients included, 47 presented with preoperative IKP. Compared with patients without IKP, the IKP cohort had comparable knee structural abnormalities (all with P > .05). Still, the IKP cohort showed inferior preoperative values for the mHHS (P = .003), iHOT-12 score (P = .016), hip VAS score (P = .001), and weekly sports participation (P = .039). Postoperatively, the IKP cohort had a lower mHHS (P = .046), lower iHOT-12 score (P = .037), and lower hip VAS score (P = .003) and were less likely to achieve the PASS for the mHHS (P = .021) and iHOT-12 score (P = .049). Patients with higher knee VAS scores were less likely to achieve the PASS for the mHHS (odds ratio, 0.61; P = .023). Within the IKP group, the knee VAS score improved from 2.3 to 1.0 (P < .001). Patients with alleviated IKP showed superior postoperative iHOT-12 scores (P = .038) compared with patients with persistent IKP.

CONCLUSIONS

Concomitant IKP at baseline negatively affected preoperative status and short-term clinical outcomes after arthroscopic treatment of FAIS. Patients with IKP were less likely to meet clinical thresholds. Most patients achieved IKP alleviation postoperatively, which was associated with superior clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.