Analysis of the referral pattern and wait time for hip arthroscopy in a single payer publicly funded health care system

Editorial Commentary: Earlier Hip Arthroscopy May Result in Improved Outcomes for Femoroacetabular Impingement Syndrome in Symptomatic Athletes: No Time Like the Present Could Mean Better Luck Next Year

Hip arthroscopy is an effective tool to address hip pain and dysfunction related to femoroacetabular impingement syndrome (FAIS), and an increasing volume of evidence suggests improved outcomes of these procedures if they are done closer to the onset of symptoms. Although this same relationship is observed in competitive athletes, these patients often have competing priorities when deciding if and when to proceed with surgical management of FAIS, including the desire to complete a competitive season, scouting and scholarship considerations, and financial incentives. Despite these incentives, consideration may be given to earlier surgical management, given the improved outcome potential and high rates of return to play. However, caution should be taken, particularly in the elite athlete population, as return to play data may not paint the whole picture, and there remains a paucity of data on sport performance after hip arthroscopy for FAIS.

Psychological Healthcare Burden Lessens After Hip Arthroscopy for Those With Comorbid Depression or Anxiety

Purpose

In this study, we investigated whether patients undergoing arthroscopic treatment of femoral acetabular impingement syndrome (FAIS) seek health care for treatment of comorbid depression and anxiety in the year following hip arthroscopy.

Methods

Using the Truven Health Marketscan database, FAIS patients who underwent hip arthroscopy between January 2009 and December 2016 were identified. Claims related to depression or anxiety filed during the year before surgery were required for inclusion. Using claims for pharmaceutical and psychological therapy treatments for mental health disorders, four groups of patients were analyzed on the basis of preoperative anxiety/depression treatment: medication only, therapy only, medication + therapy, and no treatment. Number of opioid pain prescriptions within 180 days prior to surgery and >90 days after hip arthroscopy were also compared.

Results

Depression and anxiety claims were identified in 5,208/14,830 (35.1%) patients. Preoperative treatment for depression and anxiety included medication only (n = 648, 12.4%), therapy only (n = 899, 17.3%), medication + therapy (n = 252, 4.8%), and no treatment (n = 3,409, 65.5%). Of the 900 patients who filled an anxiety/depression-related prescription prior to surgery, 422 (46.9%) patients did not fill a similar prescription in the postoperative year. Of the 1,151 patients receiving anxiety/depression-related therapy prior to surgery, 549 (47.7%) did not receive therapy in the postoperative year. Preoperative opioid prescriptions were filled for 393 patients (60.6%) in medication-only group, 275 (30.6%) in therapy-only group, 156 (61.9%) in medication + therapy group, and 1,059 (31.1%) in the group receiving no treatment. Opioid prescriptions >90 days postoperatively were filled for 330 (50.9%), 225 (25.0%), 120 (47.6%), and 861 (25.3%) patients, respectively.

Conclusion

Hip arthroscopy for FAIS is associated with a decreased postoperative use of health care resources for the treatment of depression and anxiety. Clinicians should also be aware of the potential interplay between preoperative psychotropic medication use and prolonged opioid use when counseling patients.

Level of Evidence

IV, therapeutic case series.

Physiotherapy as an Initial Treatment Option for Femoroacetabular Impingement: A Systematic Review of the Literature and Meta-analysis of 5 Randomized Controlled Trials

BACKGROUND

Femoroacetabular impingement is a common and debilitating source of hip pain in young adults. Although physiotherapy is used as a mainstay of nonoperative care for femoroacetabular impingement, the evidence regarding different physiotherapy practices is poorly understood.

PURPOSE

To collect and synthesize the best available evidence and arrive at a summary estimate of treatment effect for the utility of physiotherapy in the management of femoroacetabular impingement.

STUDY DESIGN

Meta-analysis.

METHODS

A systematic review was performed on February 2, 2019, of PubMed, EMBASE, and Cochrane Library databases using "femoroacetabular impingement OR hip pain" and "physiotherapy OR nonoperative management" and their synonyms as search terms. Central treatment themes were identified across protocols, and pooled analyses were conducted to assess for differences in patient-reported outcome measures across these themes.

RESULTS

A total of 5 randomized controlled trials met our inclusion criteria. The studies included 124 patients with a mean age of 35 years, of whom 24% were male. The average follow-up was 9.4 weeks (range, 6-12 weeks), and the follow-up rate across all participants was 86%. Among these 5 studies, 4 studies used a physiotherapy protocol that focused on core strengthening versus no core strengthening, 4 studies compared active strengthening versus passive modalities, and 3 studies compared supervised versus unsupervised physiotherapy. Pooled analysis across all studies demonstrated improved outcomes in the treatment groups compared with the controls (standardized mean difference [SMD], 0.76; 95% CI, 0.38-1.13; P < .0001). Core strengthening (SMD, 0.82; 95% CI, 0.39-1.26; P = .0002), active physiotherapy (SMD, 0.70; 95% CI, 0.29-1.10; P = .0008), and supervised physiotherapy (SMD, 0.58; 95% CI, 0.14-1.03; P = .01) were found to result in statistically significant improvements in functional outcomes compared with no core strengthening, passive modalities, and unsupervised care, respectively.

CONCLUSION

Supervised physiotherapy programs focusing on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core focused programs. Future studies with longer term follow-up and validated femoroacetabular impingement specific outcome measures are required to determine prognostic factors for success with nonoperative care as well as to determine the ideal patient profile and structured rehabilitation protocol.