Arthroscopic hip preservation surgery practice patterns: an international survey

Does response to preoperative intra-articular anesthetic injections predict outcomes of femoroacetabular impingement syndrome?

INTRODUCTION

Some patients with femoroacetabular impingement syndrome (FAIS) who undergo surgery do not show satisfactory outcomes. Reliable tests that can inform prognosis of FAIS surgery are needed for optimized indications and contraindications to surgery. We aimed to review and critically appraise available literature on the capability of patient response to preoperative intra-articular anesthetic injections (PIAI) to predict post-surgical outcomes in patients with FAIS.

MATERIALS AND METHODS

This study was conducted in accordance with the PRISMA statement. Studies that assessed the patient pain response to PIAI and post-surgical outcomes in patients with FAIS were considered eligible. Study selection and data collection were performed by three independent reviewers. Main outcomes evaluated were those measured by hip outcome scales often used in assessing postoperative pain and functional recovery, such as the modified Harris Hip Score (mHHS) and international Hip Outcome Tool (iHOT). The likelihood ratio of achieving satisfactory postoperative outcomes at the mHHS (LHR) was extracted or calculated-for patients with significant response to PIAI and for those without a significant response to PIAI. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

Six studies were considered eligible for analysis. Five studies indicated that patient response to PIAI are associated to surgical outcomes for patients with FAIS, with a greater reduction in pain typically indicating a better surgical outcome. Additionally, the LHR ranged from 1.15 to 1.92 for patients with significant response to PIAI (I2 = 90.6%). For patients without a significant response, the LHR ranged from 0.18 to 0.65 (I2 = 87.5). An overall high risk of bias was observed for all studies included in the analysis. Study attrition, the prognostic factor measurement and the presence of confounding factors were the main sources of bias.

CONCLUSIONS

Greater reductions in pain with preoperative intra-articular anesthetic injections were found to be associated to better outcomes after FAIS surgery, but all available studies contain a high risk of bias.

Elimination of a Postoperative Brace Does Not Increase Complications Following Hip Arthroscopy

Background The practice of routine postoperative bracing to limit abduction and internal rotation, along with weight-bearing restrictions after hip arthroscopy (HA), varies significantly among surgeons. It is unclear whether the use of a postoperative brace improves short-term outcomes in patients undergoing HA. The purpose of this study was to determine the differences in patient outcomes before and after eliminating routine usage of a postoperative brace. Methods A retrospective review was conducted of 176 adult patients undergoing HA by a single, high-volume surgeon. The no-brace protocol was implemented in October 2020. The patients were divided into two groups: pre-implementation (January-October 2020) and post-implementation (October 2020-April 2021). Twenty-three patients that used a brace during the post-implementation period were excluded. All patients had weight-bearing restrictions with crutches for three weeks postoperatively. The primary endpoint was any complication in the first six weeks postoperatively. Results There were no significant differences in demographics between groups, although the body mass index in the brace group was higher (28.1 vs. 26.4 kg/m², p = 0.066) and the rate of additional procedures performed was higher in the brace group (55.2% vs. 40.1%, p = 0.056). There was no significant difference in postoperative outcomes between groups when looking at 90-day emergency department visits (1.7% vs. 0%, p = 0.548), complications at two (1.7% vs. 1.7%, p = 1.000) and six weeks (0% vs. 1.7%, p = 0.341) postoperatively, all complications in the first six weeks (1.7% vs. 1.7%, p = 1.000), and continued pain at six weeks (10.3% vs. 16.7%, p = 0.238). Conclusion The brace and no-brace groups were similar demographically. Patients undergoing HA with no brace and crutches experienced no significant differences in pain or complications in comparison to those receiving a traditional bracing protocol. Routine use of a postoperative brace may not be necessary in this population.

Controversial Issues in Arthroscopic Surgery for Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of painful hip in the young and middle-aged population. This condition frequently leads to a labral tear, damage of acetabular cartilage, and secondary arthritis of the hip. When nonsurgical managements are not effective, surgical procedures (open surgery and hip arthroscopy) are indicated. Due to its less invasiveness, hip arthroscopy has replaced open surgery during the last two decades. The effectiveness of arthroscopic surgery in pain relief for FAI syndrome has been well established. The procedure is also expected to slow or prevent further progression to hip arthritis. In this review, we provide the updated knowledge of arthroscopic procedures for the management of FAI syndrome.

Pain management practice patterns after hip arthroscopy: an international survey

Several post-operative pain control methods have been described for hip arthroscopy including systemic medications, intra-articular or peri-portal injection of local anesthetics and peripheral nerve blocks. The diversity of modalities used may reflect a lack of consensus regarding an optimal approach. The purpose of this investigation was to conduct an international survey to assess pain management patterns after hip arthroscopy. It was hypothesized that a lack of agreement would be present in the majority of the surgeons’ responses. A 25-question multiple-choice survey was designed and distributed to members of multiple orthopedic professional organizations related to sports medicine and hip arthroscopy. Clinical agreement was defined as > 80% of respondents selecting a single answer choice, while general agreement was defined as >60% of a given answer choice. Two hundred and fifteen surgeons completed the survey. Clinical agreement was only evident in the use of oral non-steroidal anti-inflammatory drugs (NSAIDs) for pain management after hip arthroscopy. A significant number of respondents (15.8%) had to readmit a patient to the hospital for pain control in the first 30 days after hip arthroscopy in the past year. There is significant variability in pain management practice after hip arthroscopy. The use of oral NSAIDs in the post-operative period was the only practice that reached a clinical agreement. As the field of hip preservation surgery continues to evolve and expand rapidly, further research on pain management after hip arthroscopy is clearly needed to establish evidence-based guidelines and improve clinical practice.

Survey results from an international hip course: comparison between experts and non-experts on hip arthroscopy clinical practice and post-operative rehabilitation

PURPOSE

The purpose of this study was to compare the clinical practices between expert and non-expert arthroscopy hip surgeons.

METHODS

Registered orthopedic surgeons completed anonymous surveys during a hip arthroscopy meeting. The survey included 60 questions on physician's level of expertise, surgical anesthesia, procedures performed, hospital stay, pain control, rehabilitation and socioeconomic parameters, and the results are presented. Comparisons were made between hip arthroscopy experts (> 500 cases performed) and non-experts (≤ 500 cases performed) on aspects of patient care.

RESULTS

Forty-eight (74%) surgeons responded. Forty-four questionnaires were filled out completely. There were no significant differences in recommendations between 15 (34%) hip arthroscopy experts and 29 (66%) non-experts on hip capsular management and cartilage repair techniques, use of antithrombotic prophylaxis and opioid analgesics, time of rehabilitation initiation and patient compliance factors, use of hip brace and CPM, and patient evaluation to return to sports following surgery. Surgical expertise was significantly associated with the performance of hip labral reconstruction (p = 0.016), subspine decompression (p = 0.039) and recommendation of a longer period of restricted weight bearing following the performance of microfractures (p = 0.011). There were no significant differences in clinical practice between surgeons who performed hip arthroscopy exclusively versus those who did not.

CONCLUSIONS

Hip arthroscopy is a relatively new field, and clinical practice may vary among physicians based on the surgical expertise. In this study, hip arthroscopy experts agree with non-experts on most aspects of patient care. Surgical expertise was associated with performance of advanced techniques and recommendation of longer period of restricted weight bearing following performance of microfractures. This study highlights different care patterns that need to be investigated to determine which treatment results in improved patient care.

LEVEL OF EVIDENCE

V.

The impact of the 30 most cited articles on hip arthroscopy: what is the subject matter?

The purpose of this study was to identify the 30 most cited articles on hip arthroscopy and discuss their influence on recent surgical treatment. Due to advancements in hip arthroscopy, there is a widening spectrum of diagnostic and treatment indications. The purpose of this study was to identify the 30 most cited articles on hip arthroscopy and discuss their influence on contemporary surgical treatment. The Thomson Reuters Web of Science was used to identify the 30 most cited studies on hip arthroscopy between 1900 and 2018. These 30 articles generated 6152 citations with an average of 205.07 citations per item. Number of citations ranged from 146 to 461. Twenty-five out of the 30 papers were clinical cohort studies with a level of evidence between III and IV, encompassing 4348 patients. Four studies were reviewed (one including a technical note) and one a case report. We were able to identify the 30 most cited articles in the field of hip arthroscopy. Most articles were reported in high-impact journals, but reported small sample sizes in a retrospective setting. Prospective multi-arm cohort trials or randomized clinical trials represent opportunities for future studies.

Practice patterns for the treatment of acute proximal hamstring ruptures

Objective: Proximal ischial hamstring avulsion injuries are relatively uncommon. As such, the management of these injuries is often highly variable. Consensus agreement is lacking for the indications for repair, along with the operative technique, and post-operative rehabilitation. The purpose of this study was to survey surgeons who treat proximal hamstring avulsion injuries to identify current trends in the management of this injury.Methods: After IRB approval, a 46-question cross-sectional survey was distributed using a secure electronic survey portal. The survey sought to determine surgeon experience, diagnostic preferences, treatment patterns, surgical indications/technique, perceived patient outcomes, surgical complications, as well as post-operative management and rehab protocols. Surveys were completed electronically and anonymously, with invitations distributed to members of the American Orthopedic Society for Sports Medicine (AOSSM) and Arthroscopy Association of Canada (AAC).Results: A total of 108 surgeons who manage proximal hamstring injuries completed the survey. Most respondents (77%) treat one to five of these injuries per year. MRI was the preferred imaging modality to confirm diagnosis. Despite 98% of respondents indicating that there was a role for surgical management of proximal hamstring avulsions, operative treatment was reportedly undertaken in only 50% of cases seen by each respondent. The top three reported surgical indications were: number of tendons involved (most important factor = 42%, second most = 26%, third most = 13%), amount of tendon retraction (28%, 41%, 16%), and patient activity level (16%, 18%, 24%).Conclusion: Based on the practice patterns of the surgeons who completed the survey, there is continued disparity in the management of proximal hamstring avulsions. A lack of agreement exists with regards to surgical indications, operative technique, and post-operative protocols. Most striking is the rate of non-operative treatment and perceived rate of poor outcomes within this cohort. Future research should focus on objective evaluation of non-operative management, and additional variables involved in surgical treatment and post-operative rehabilitation.

Hip Arthroscopy: A Social Media Analysis of Patient Perception

Background

The rate of hip arthroscopy has increased significantly in recent years, although understanding of patient perception remains limited.

Purpose

To analyze posts shared on Instagram and Twitter referencing hip arthroscopy to evaluate perspective, tone, timing, content, visibility, and location.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

A search of public posts on Instagram and Twitter was performed over a 1-year period, selected through use of the following hashtags: #hiparthroscopy, #hipscope, and #labralrepair. A total of 1850 Instagram posts and 163 Twitter posts were included in the analysis. A categorical classification system was used for media format (picture or video), perspective (patient, family or friend, physician, hospital or physical therapy group, professional organization, news media, or industry), timing (preoperative, postoperative, nonoperative), perioperative period (within 1 week before or after surgery), tone (positive, negative, or neutral), and content (surgical site, hospital or surgeon, imaging, rehabilitation, activities of daily living (ADLs), return to work, surgical instruments, or education). Post popularity (number of likes) and geographic location were also recorded.

Results

Of the 1850 Instagram posts analyzed, 91.2% were made by patients, and 52.9% were positive. The most common content included in Instagram posts was rehabilitation, ADLs, and hospital or surgeon. A total of 163 Twitter posts were analyzed, with 59.0% of posts made by physicians. A majority of posts had a positive tone, and the most frequently referenced themes included education, hospital or surgeon, and rehabilitation. Overall, posts originated from 24 different countries.

Conclusion

The majority of patients who undergo hip arthroscopy have a positive tone when discussing their procedure. Posts commonly focused on rehabilitation, ADLs, hospital or surgeon, and education. This analysis provides insight into patient perspectives toward hip arthroscopy.