The effect of platelet enriched plasma on clinical outcomes in patients with femoroacetabular impingement following arthroscopic labral repair and femoral neck osteoplasty

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.

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.

Knotless Versus Knotted Suture Anchors for Labral Repair of the Hip: A Systematic Review of Clinical and Biomechanical Outcomes

BACKGROUND

Arthroscopic labral repair of the hip is successfully performed with increasing frequency using either knotless or knotted suture anchors, each with its own risks and benefits.

PURPOSE

To examine biomechanical and clinical outcomes for labral repair of the hip based on the use of knotted or knotless suture anchors.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search was performed to retrieve clinical and biomechanical studies examining the use of knotless or knotted suture anchors for arthroscopic labral repair of the hip. The studied outcomes included functional outcome scores such as modified Harris Hip Score (mHHS) and Hip Outcome Score Activities of Daily Living, biomechanical outcomes, failure mechanisms, and complications such as revision/reoperation and conversion to total hip arthroplasty (THA).

RESULTS

A total of 47 articles met inclusion criteria for analysis (5 articles examining biomechanical outcomes and 42 reporting clinical outcomes). Included patients (N = 6185) who underwent hip labral repair had a mean age of 33.0 ± 8.5 years and follow-up time of 43.8 ± 18.4 months. The knotless group (n = 2719) had a mean preoperative mHHS of 63.3 ± 4.1 and postoperative mHHS of 86.3 ± 2.8 at a mean follow-up time of 47.2 ± 16.1 months. The knotted group (n = 2600) had a mean preoperative mHHS of 69.5 ± 8.3 and postoperative mHHS of 88.8 ± 5.5 with a mean follow-up time of 44.8 ± 18.1 months. The most common reason for failure of knotless anchors in biomechanical studies was suture breakage or pullout, and for knotted anchors it was anchor pullout. Of the articles reporting on revisions and/or conversion to THA after labral repair, the knotless group had 225 reoperations (8.1%) and 123 cases of conversion to THA (4.4%). The knotted group had 101 reoperations (6.2%) and 31 cases of conversion to THA (1.9%).

CONCLUSION

Arthroscopic management of labral repairs of the hip using either knotless or knotted suture anchors appears to be both safe and effective in reducing pain and improving function. Biomechanical evaluation suggests differing failure mechanisms in knotted versus knotless anchors. The rates of revision and conversion to THA are low overall, irrespective of knotted or knotless anchors.

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.

Chondral regeneration in femoroacetabular lesions is favoured using peripheral blood stem cells with hyaluronan-based scaffold and micro-drilling: A prospective cohort study

Purpose

To determine whether intra-articular injections of peripheral blood stem cells (PBSC) with hyaluronan (HA)-based scaffold improve articular cartilage regeneration in chondral injuries caused by mixed-femoroacetabular impingement syndrome (FAIS) over a period longer than 24 months post-hip arthroscopy.

Methods

In this prospective cohort study, patients with mixed-FAIS and chondral injury ≥ IIIB according to the International Cartilage Regeneration and Joint Preservation Society grade or III/IV of Konan/Haddad classification underwent intra-articular injection of PBSC with an HA-based scaffold and micro-drillings during hip arthroscopy. The degree of chondral repair was measured at baseline and 5 years using the International Cartilage Repair Society morphologic score system (MSS) as the primary outcome. Pain was measured at baseline and 5 years using the Visual Analogue Scale for Pain (VAS Pain), and hip functionality was measured at baseline (presurgery), 6 months, 1 year, and 5 years using the Hip Outcome Score (HOS). The largest diameter of injury, median follow-up, side effects, complications, and improvements were described. T-test, ANOVA with multiple comparisons, and statistical power were estimated.

Results

From initially 34 cases, 25 patients were enrolled. The median follow-up was 5.1 ± 0.3 years. One patient (4%) reported a few side effects with filgrastim administration. No infection, tumours, or synovitis was reported. The largest diameters in zones two, three, and four were 12.4 ± 3.1 mm (n = 8), 13.5 ± 2.8 mm (n = 14), and 11.4 ± 1.9 mm (n = 3), respectively. Ninety-two percent (23/25) of patients improved their outcomes. The MSS and HOS increased from 3.8 ± 1.1 to 9.6 ± 1.5 pts (p < 0.001) and from 65.5 ± 13.0 to 93.9 ± 2.4 pts (p < 0.001), respectively. The VAS-Pain decreased from 5.3 ± 0.7 to 1.3 ± 0.6 mm (p < 0.001). The obtained a posteriori power-size was 0.99.

Conclusion

The intervention suggests a favourable impact on articular cartilage regeneration and clinical outcomes for hip chondral lesions in mixed-FAIS injuries after a median follow-up of 5.1 ± 0.3 years.

Level of Evidence

Level IV.

Patient Outcomes Are Not Improved by Platelet-Rich Plasma Injection Onto the Capsule at the Time of Closure During Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Purpose

To determine the effect of platelet-rich plasma (PRP) injection onto the capsule at time of closure on outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

Methods

Patients who underwent hip arthroscopy between January 2014 and December 2021 were retrospectively identified. The first cohort included patients who received PRP injection onto the capsule following capsular closure at the conclusion of the case. The second cohort did not receive PRP. Pain scores on a visual analog scale, Modified Harris Hip Scores, Single Assessment Numeric Evaluation (SANE), as well as Patient-Reported Outcomes Measurement Information System Physical Function scores were obtained preoperatively as well as at multiple time points postoperatively up to 2 years.

Results

In total, 345 patients were included in the study, with 293 in the PRP cohort and 52 in the non-PRP cohort. There was no significance difference in age (P = .69), sex, or preoperative pain (P = .92) and patient-reported outcome scores between the 2 groups (modified Harris Hip Score, P = .38; Patient-Reported Outcomes Measurement Information System Physical Function, P = .48), except for preoperative SANE scores, which had a greater baseline in the PRP group (P < .001). Using both observed data as well as repeated measure analysis of variance model to estimate for missing data after baseline, we found there were no differences in visual analog scale pain scores nor patient-reported outcome scores at any time point. There was similarly no difference in change from baseline for SANE scores. There was no difference in rate of revision surgery between the 2 cohorts (P = .66).

Conclusions

Based on the results of this study, intraoperative PRP injection onto the capsule at the time of capsular closure does not improve outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement syndrome.

Level of Evidence

Level III, retrospective comparative study.

Orthobiologics as an adjunct in treatment of femoroacetabular impingement syndrome: cell-based therapies facilitate improved postoperative outcomes in the setting of acetabular chondral lesions-a systematic review

PURPOSE

To evaluate studies utilizing orthobiologics in the management of femoroacetabular impingement syndrome (FAIS) to (1) assess the indications for usage, and (2) analyze patient-reported outcome measures (PROM) following treatment. It was hypothesized that orthobiologics would (1) be utilized for symptomatic FAIS in the setting of labral or chondral pathology, and (2) improve PROM at most recent follow-up.

METHODS

The Pubmed, Ovid Medline, Cochrane, and Web of Science databases were searched for clinical studies evaluating orthobiologics [hyaluronic acid (HA), platelet-rich plasma (PRP), or cell-based therapy (CBT) for treatment of FAIS. Exclusion criteria included orthobiologics used in conjunction with cartilage transfer or scaffolding procedures and a primary indication other than FAIS. Data collection included patient demographics, indications, and baseline and most recent PROM.

RESULTS

Eleven studies (one level I, four level II, four level III, and two level IV evidence) met inclusion criteria, consisting of 440 patients with mean ages ranging from 32.8 to 47 years. All 11 studies demonstrated an improvement in PROM from baseline to most-recent follow-up. Four studies administered PRP either intraoperatively or the day after surgery as an adjunct to labral repair. CBT was used intraoperatively in the setting of acetabular chondral lesions (three studies) and labral repair (one study). When comparing to a control group at most recent follow-up, three PRP cohorts demonstrated similar PROM (n.s.), while one PRP group exhibited worse visual analog pain scores (2.5 vs. 3.4, p = 0.005) and modified Harris Hip Scores (mHHS) (82.6 vs. 78.7, p = 0.049). The four CBT studies reported favorable results compared to a control group, with a significantly higher mHHS at most recent follow-up or mean improvement from baseline in Hip Outcome Score-Activities of Daily Living (p < 0.05). Three studies reported on HA, which was utilized exclusively in the nonoperative setting.

CONCLUSIONS

Intraoperative PRP and CBT have been commonly reported in the setting of hip arthroscopy for labral repairs and acetabular chondral lesions, respectively. The CBT cohorts demonstrated more favorable PROM at most recent follow-up when compared to a control group, though these results should be interpreted with caution due to heterogeneity of orthobiologic preparations.

LEVEL OF EVIDENCE

IV.

Inflammatory and Immunologic Contributions in Femoroacetabular Impingement Syndrome

Femoroacetabular impingement (FAI) is one of the most common causes of labral and early cartilage damage in the nondysplastic hip. FAI is increasingly recognized as a cause for hip and groin pain in the young, active patient, and the surgical treatment of FAI with hip arthroscopy has risen exponentially. Although our understanding of FAI and the progression to degenerative osteoarthritis of the hip has historically been considered a mechanical "wear-and-tear" disease of an imperfectly shaped, aspherical, femoral head within a deep or overcovering acetabulum leading to cartilage injury, our understanding of the intrinsic pathophysiologic mechanisms underlying the development of FAI and joint degeneration of the hip remains poor. For example, many patients with FAI morphology may never develop hip pain or osteoarthritis; there remains more to discover regarding the pathophysiology of arthritis in the setting of FAI. Recent work has begun to identify a strong inflammatory and immunologic component to the FAI disease process that affects the hip synovium, labrum, and cartilage and may be detectable from peripheral clinical samples (blood and urine). This review highlights our current understanding of the inflammatory and immunologic contributions to FAI and potential therapeutic strategies to supplement and augment the surgical management of FAI.

Platelet-Rich Plasma Is Not Associated With Improved Outcomes Following Hip Femoroacetabular Impingement Surgery: Very Low-Quality Evidence Suggests Hyaluronic Acid and Cell-Based Therapies May Be Beneficial—A Systematic Review of Biological Treatments

Purpose

To examine the efficacy of biologic agents in the treatment of cartilage defects associated with femoroacetabular impingement (FAI).

Methods

PubMed, Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were reviewed by 2 independent reviewers for eligible studies. We included randomized and nonrandomized control trials as well as uncontrolled case series and retrospective studies. Studies were excluded if they included injections of corticosteroids, papers that described technique only, review papers, and those not in the English language. Demographics, treatment type, outcome of treatment, and complications were extracted, whereas risk of bias and study quality were assessed independently using the risk of bias tool (ROB2) and effective public health practice project tool. A narrative synthesis was performed, and standardized mean differences were reported. Certainty of evidence was assessed using the GRADE approach.

Results

Eighteen studies consisting of 1,024 patients met the inclusion criteria. Three studies involved the use of platelet-rich plasma (PRP) as an adjuvant to surgery and were included in the meta-analysis. Three studies administered hyaluronic acid (HA) as a primary treatment. Twelve involved various cell-based methods of chondrocyte stimulation for cartilage defects associated with FAI, but heterogeneity did not allow for pooling. Low-quality evidence indicates PRP is not associated with improved outcomes following surgery (mean difference –1.42, 95% confidence interval –3.95 to 1.11, P = .27). Very-low-quality evidence suggests HA (standardized mean difference 1.15, 95% confidence interval 0.64-1.66, P < .001, Z = 4.39) and cell-based therapies may improve function and pain in patients with FAI.

Conclusions

Low-quality evidence indicates PRP is not associated with improved outcomes following hip FAI surgery, and very-low-quality evidence suggests HA and cell-based therapies may improve outcomes.

Level of Evidence

systematic review of Level I-V studies.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.

PURPOSE

To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.

RESULTS

Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

CONCLUSION

Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

Biological Augments for Acetabular Chondral Defects in Hip Arthroscopy-A Scoping Review of the Current Clinical Evidence

PURPOSE OF REVIEW

A wide array of joint-preserving surgical techniques exists in the management of acetabular chondral defects (ACDs). The purpose of this review is to summarize the clinical outcomes of the recent biologics used to treat ACDs during hip arthroscopy.

RECENT FINDINGS

Increasing evidence is available for different biological solutions used in the hip. Studies have shown promising outcomes with minimal complications when using biologics as augmentation to microfracture (MF), including different scaffolds or stem cells, or to enhance autologous chondrocyte implantation (ACI). However, data so far is scarce, and more trials and longer follow-ups are needed to better delineate the appropriate indications and benefits for each technique. Presently, the level of evidence is low, but in general, biologics appear safe and trend toward beneficial compared to standard surgical techniques. Augmented MF is recommended for small to medium ACDs, and matrix-assisted ACI or three-dimensional ACI is recommended for medium to large defects.

The use of biologics to improve patient-reported outcomes in hip preservation

Despite lack of clear understanding, the use of biologic treatment methods has increased in the United States. Therapeutic methods, including platelet-rich plasma (PRP), bone marrow aspirate concentrate (BMAC) and hyaluronic acid (HA) among other biologics, are commonly associated with relief of pain in a number of different orthopedic conditions. Within the past two decades, hip preservationists have investigated the roles of these biologic treatments in both non-operative and surgical management of common hip conditions. The purpose is to review the published literature surrounding the application and efficacy of biologics, most notably PRP, BMAC and HA, in the clinical management of hip conditions. The hip conditions examined in this review include hip osteoarthritis, femoroacetabular impingement syndrome and associated labral tear pathology, avascular necrosis of the femoral head and gluteal/hamstring tendinopathy. While our review of the literature suggests that there is support for the implementation of biologics to relieve pain and improve function for hip conditions. Through further research efforts, it is important to stay updated with the clinical efficacy of biologics in hip preservation.

Peri-operative platelet-rich plasma in arthroscopic femoroacetabular impingement surgery: a randomized controlled trial

This study aimed to determine whether the addition of platelet-rich plasma (PRP) during hip arthroscopy improves functional outcomes in femoroacetabular impingement (FAI) surgery. This was a prospective randomized single-blinded trial of arthroscopic hip patients aged between 16 and 50 years with a diagnosis of FAI conducted at a single centre. Patients with any previous hip surgery and significant osteoarthritic changes (Tonnis grade > 2) were excluded. Before surgery, patients were randomly assigned to receive either a PRP injection or a saline placebo. Efficacy was evaluated at 6 months, 1 year and 2 years post-surgery using patient-reported outcomes. The short version International Hip Outcome Tool (iHOT12) was the primary outcome. Recruited patients (n = 113) were aged 36.0 ± 10.5 (mean ± standard deviation) years and 56% male. At baseline, iHOT12 scores of the PRP (mean 43.8 ± 22.4) and placebo groups (mean 45.2 ± 21.5) were similar. At a minimum follow-up of 2 years, both groups had improved iHOT12 scores (PRP: mean 83.6 ± 13.4, control: mean 77.1 ± 23.3), with no significant difference in change between the two groups (P = 0.19). There were no significant group differences for the change in Non-Arthritic Hip and Hip Disability and Osteoarthritis Outcome Score—Shortform scores between the two groups (P = 0.22 and 0.46, respectively). The present study does not support the peri-operative use of PRP in arthroscopic surgery for FAI for mid-term improvement. There were no significant differences in outcome between PRP and placebo groups at 2-year minimum follow-up after surgery.

The Use of Biologics for Hip Preservation

PURPOSE OF REVIEW

A wide array of nonoperative modalities to treat hip pain are aimed at restoring and maintaining the structural and physiologic characteristics of the joint. The purpose of this review is to describe the current understanding of biologics in hip pathology by providing an evidence-based overview of treatment modalities available for orthopedic surgeons.

RECENT FINDINGS

The use of biologics as a primary treatment or adjunct to traditional management has shown encouraging results for the treatment of hip pain. Studies have demonstrated safety with minimal complications when using platelet rich plasma, hyaluronic acid, or stem cells to treat hip pain caused by osteoarthritis, femoroacetabular impingement syndrome, tendinopathy, or osteonecrosis of the femoral head. Several studies have been able to demonstrate meaningful clinical results that can improve treatment standards for hip pain; however, more work must be performed to better delineate the appropriate protocols, indications, and limitations of each modality. Recent advances have inspired renewed interest in biologics for patients with hip pain. We present a concise review of platelet rich plasma, hyaluronic acid, stem cells, and matrix metalloprotease inhibitors and their applicability to hip preservation surgery.

Increased range of motion but otherwise similar clinical outcome of arthroscopy over open osteoplasty for femoroacetabular impingement at midterm follow-up: A systematic review

BACKGROUND

A systematic review was conducted comparing patient reported outcomes measures (PROMs), functional scores, and the rate of complications between arthroscopic and open treatment for femoroacetabular impingement (FAI) at mid-term follow-up.

MATERIAL AND METHODS

This systematic review was performed according to the PRISMA guidelines. The literature search was performed in October 2020. All clinical trials treating FAI using open osteoplasty or arthroscopic surgery were considered for inclusion. Only articles reporting >12 months follow-up were included.

RESULTS

Data from 97 articles (9981 procedures) were collected. At a mean 19.2 months follow-up there was no difference between the two cohorts. At a mean follow-up of 38 months, the external rotation was increased in the arthroscopic group (P < 0.0001). The modified Harris Hip Score scored greater in favour of the open osteoplasty group (P = 0.04), as did the Hip Outcome Score - Activities of Daily Living subscale (P = 0.01). At a mean 45.1 months the arthroscopic group presented greater external rotation (P < 0.0001) and SF-12 Mental (P = 0.04). The modified Harris Hip Score was greater in favour of the open osteoplasty group (P = 0.03), as was the HOS-ADL (P = 0.01). Regarding complications, the arthroscopic group experienced lower rates of subsequent revisions (P < 0.0001).

CONCLUSION

Based on the significant reduction of revisions-rate and significant increase in range of motion, arthroscopy treatment for the management of FAI may be recommended.

Preparation Methods and Clinical Outcomes of Platelet-Rich Plasma for Intra-articular Hip Disorders: A Systematic Review and Meta-analysis of Randomized Clinical Trials

Background:

Despite its increasing use in the management of musculoskeletal conditions, questions remain regarding the preparation methods of platelet-rich plasma (PRP) and its clinical applications for intra-articular hip disorders, including femoroacetabular impingement syndrome (FAIS), labral pathology, and osteoarthritis (OA).

Purpose:

To systematically review and assess the preparation methods and clinical outcomes from randomized clinical trials (RCTs) on the use of PRP for intra-articular hip disorders.

Study Design:

Systematic review; Level of evidence, 2.

Methods:

A systematic review in accordance with the 2009 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines was performed in September 2019. The Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, PubMed, Ovid Medline, and Embase were queried for studies regarding the use of PRP to treat intra-articular hip disorders. Qualifying articles were English-language RCTs describing the use of PRP for intra-articular hip disorders, either as standalone treatment or surgical augmentation. Two authors independently assessed article eligibility. Data pertaining to patient characteristics, indication for treatment, PRP preparation method, follow-up period, and clinical outcomes were extracted. Study results were qualitatively reported and quantitatively compared using meta-analysis when appropriate.

Results:

Seven RCTs met inclusion criteria. Four studies described the use of PRP for hip OA and 3 utilized PRP at arthroscopy for FAIS and labral tears. Outcomes after PRP for OA demonstrated improvement in validated patient-reported outcome measures for up to 1 year; however, pooled effect sizes found no statistically significant difference between PRP and hyaluronic acid (HA) regarding pain visual analog scale scores at short-term (≤2 months; P = .27), midterm (4-6 months; P = .85), or long-term (1 year; P = .42) follow-up. When injected at arthroscopy, 1 study reported improved outcomes, 1 reported no difference in outcomes, and 1 reported worse outcomes compared with controls. The meta-analysis demonstrated no statistically significant difference on the modified Harris Hip Score (mHHS) between PRP and control cohorts at a minimum 1-year follow-up. There were considerable deficiencies and heterogeneity in the reporting of PRP preparation methods for both indications.

Conclusion:

Treatment of OA with PRP demonstrated reductions in pain and improved patient-reported outcomes for up to 1 year. However, there was no statistically significant difference between PRP and HA in pain reduction. Likewise, for FAIS and labral surgery there was no statistically significant difference in mHHS outcomes between patients treated with PRP and controls. Given the limited number of studies and variability in PRP preparations, additional high-quality randomized trials are warranted.

Does Platelet-rich Plasma Augmentation Following Hip Arthroscopy Improve Outcomes: A Systematic Review

Platelet-rich plasma (PRP) has gathered widespread acceptance among orthopaedic surgeons because of its multimodal effects on tissue healing. Varying results have been reported when PRP injections are combined with hip arthroscopic surgery. To evaluate the influence of PRP on clinical outcomes following hip arthroscopy. We hypothesized that patients treated with PRP would have improved postoperative outcome scores. A search of the National Institute for Health and Care Excellence (NICE) healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE, and AMED databases) was conducted from their years of inception to May 2018 with the keywords: "Hip Arthroscopy" and "Platelet-Rich Plasma". A quality assessment was performed based on the Cochrane risk of bias tool. Three studies were included for analysis; two of which had low risk of bias. The studies included 363 hips, of which 141 were randomised for PRP treatment. The mean age of all patients was 35 years and the follow-up ranged from 18.5 to 36 months. Authors used different PRP systems and preparations. Modified Harris hip score was reported in all three studies with two studies favouring the use of PRP. The use of PRP following hip arthroscopy did not lead to significantly improved postoperative pain or functional outcomes when compared to control groups in the studies included in this review.

Use of Biologics as an Adjunct Therapy to Arthroscopic Surgery for the Treatment of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

There has been a recent increase in the use of biologics in hip arthroscopy to assist in the management of femoroacetabular impingement (FAI).

PURPOSE

To analyze the current use of biologics for the treatment of FAI and its associated lesions.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search of the PubMed, Medline, and EMBASE databases was performed in March 2019 with use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The criterion for inclusion was observational, published research articles studying the therapeutic use of biologics as an adjuvant therapy during arthroscopic surgery for FAI; treatments included bone marrow aspirate concentrate, mesenchymal stem cells (MSCs), platelet-rich plasma (PRP), hyaluronic acid, growth factors, and autologous chondrocyte implantation (ACI) or autologous matrix-induced chondrogenesis (AMIC).

RESULTS

There were 9 studies that met the inclusion criteria, and a total of 674 patients were included across all studies. FAI was studied in all articles. Further, 7 studies (78%) also analyzed chondral injuries, and 3 studies also analyzed labral tears (33%). ACI or AMIC was used in 56% of studies and showed superior functional outcomes at short- and midterm follow-up versus debridement or microfracture. PRP did not improve the outcome of labral repairs at short-term follow-up.

CONCLUSION

The current literature regarding biologic adjuncts in hip arthroscopy is varied in quality, with only one level 1 study. The use of ACI/AMIC for medium-sized chondral lesions showed promising results in individual studies; however, these were of lower quality. To enable comparisons among future studies, investigators must ensure accuracy in the reporting of biologic preparations and formulations used and homogeneity in the type and severity of lesion treated.