Arthroscopic Hip Surgery versus Conservative Therapy on Femoroacetabular Impingement Syndrome: A Meta-Analysis of RCTs

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.

In Vitro Ovine Cam Impingement Model and Its Effect on Acetabular Cartilage

Background

Femoroacetabular impingement syndrome is a condition where abnormal contact occurs between the femoral head and the acetabulum, leading to chondral damage and hip osteoarthritis. To better understand and treat femoroacetabular impingement syndrome, it is crucial to establish in vitro models that mimic the condition and assess potential interventions.

Purpose

To establish an in vitro ovine cam impingement model and assess the effectiveness of cam excision in reducing the incidence of type 3 acetabular labrum articular disruption (ALAD) (chondral flap) lesions.

Study Design

Controlled laboratory study.

Methods

Utilizing an ovine in vitro cam impingement model, 40 hips were subjected to testing across 5 groups (n = 8 per group): group 1 (control group), 750 N for 200 cycles; group 2 (cycle decrease), 750 N for 100 cycles; group 3 (load decrease), 500 N for 200 cycles; group 4 (cam excision), cam excision followed by 750 N for 200 cycles; and group 5 (halfway cam excision), 750 N for 100 cycles followed by cam excision under an additional 750 N for 100 cycles loading. Each specimen was subsequently assessed for chondral damage according to the ALAD classification, both macroscopically and microscopically.

Results

The control group (group 1) demonstrated the highest ALAD scores (2.7 ± 0.4, 2.8 ± 0.3) compared with other groups, whereas the cam excision group (group 4) exhibited lower scores (0.5 ± 0.5, 0.7 ± 0.4) than both the cycle decrease group (group 2) (1.6 ± 0.5, 1.6 ± 0.5) and the halfway cam excision group (group 5) (1.8 ± 0.6, 2 ± 0.5) (P < .05) in both macroscopic and microscopic gradings (P < .05). The load decrease group (group 3) (1 ± 0.5) also displayed lower scores compared with group 5 (2 ± 0.5) at histological grading (P < .05).

Conclusion

An in vitro sheep model was established that reliably induces mechanical chondrolabral damage in the hip joint. The findings show that reducing the load results in less chondrolabral damage compared with reducing the number of cycles. Furthermore, this model emphasizes the protective effect of cam excision in the management of chondral flap lesions (ALAD type 3).

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.

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.

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).

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.

Basics of hip arthroscopy: Step-by-step technique

Hip arthroscopy is a surgical procedure that has a technically challenging nature, requiring advanced spatial skills and specialised instrumentation. The most common indication for hip arthroscopy is femoroacetabular impingement, which is increasing due to improved awareness and knowledge of the condition among healthcare professionals. Hip arthroscopy requires many different checkpoints from patient positioning to capsule closure to be successfully completed. Patient positioning is one of the keystones of hip arthroscopy and the probability of a surgeon achieving successful outcomes is significantly influenced by the establishment of optimal access points. The importance of the acetabular labrum and capsule has been better understood in recent years. There has been a noticeable preference towards prioritising acetabular labral repair over debridement or excision. Similarly, consistent with the literature, capsule closure restores naive hip biomechanics more successfully and improves functional outcomes following hip arthroscopy. Osteochondroplasty is a frequently employed therapeutic intervention; yet, attaining optimal osteochondroplasty outcomes might present challenges. The aim is, to restore the full perfect sphericity of the femoral head without attenuation of the head. The aim of this article is to highlight the knowledge accumulated from experiences based on previous hip arthroscopy surgeries as a solution for future troubleshooting steps. Level of Evidence: Level V.

Hypoalgesia after aerobic exercise in healthy subjects: A systematic review and meta-analysis

Exercise-Induced Hypoalgesia (EIH) refers to an acute reduced pain perception after exercise. This systematic review and meta-analysis investigated the effect of a single aerobic exercise session on local and remote EIH in healthy individuals, examining the role of exercise duration, intensity, and modality. Pressure pain thresholds (PPT) are used as the main measure, applying the Cochrane risk of bias tool and GRADE approach for certainty of evidence assessment. Mean differences (MD; Newton/cm²) for EIH effects were analysed. Thirteen studies with 23 exercises and 14 control interventions are included (498 participants). Most studies used bicycling, with only two including running/walking and one including rowing. EIH occurred both locally (MD = 3.1) and remotely (MD = 1.8), with high-intensity exercise having the largest effect (local: MD = 7.5; remote: MD = 3.0) followed by moderate intensity (local: MD = 3.1; remote: MD = 3.0). Low-intensity exercise had minimal impact. Neither long nor short exercise duration induced EIH. Bicycling was found to be effective in eliciting EIH, in contrast to the limited research observed in other modalities. The overall evidence quality was moderate with many studies showing unclear risk biases.

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.

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). The iHOT-33 and HOS ADL scales showed significant differences at 12 months in favor of the arthroscopy group (MD, 10.65; 95% CI 6.54-4.76) and (MD, 8.09; 95% CI 3.11-13.07). MCID was not achieved through arthroscopy in functional variables. The rates of osteoarthritis (OR, 6.18; 95% CI 1.06-36.00) and numbness (OR, 73.73; 95% CI 10.00-43.92) were significantly higher in the arthroscopy group. Arthroscopic surgery showed statistical superiority over the control group without exceeding the MCID in most studies; however, the results might have been influenced by secondary variables. Finally, arthroscopic surgery results in a high rate of conversion to osteoarthritis.

Harms Reporting Is Inadequate in Systematic Reviews Regarding Hip Arthroscopy

Purpose

To investigate the quality of harms reporting in systematic reviews (SRs) regarding hip arthroscopy in the current literature.

Methods

In May 2022, an extensive search of 4 major databases was performed identifying SRs regarding hip arthroscopy: MEDLINE (PubMed and Ovid), EMBASE, Epistemonikos, and Cochrane Database of Systematic Reviews. A cross-sectional analysis was conducted, in which investigators performed screening and data extraction of the included studies in a masked, duplicate fashion. AMSTAR-2 (A Measurement Tool to Assess Systematic Reviews-2) was used to assess the methodologic quality and bias of the included studies. The corrected covered area was calculated for SR dyads.

Results

A total of 82 SRs were included in our study for data extraction. Of these SRs, 37 reported under 50% of the harms criteria (37 of 82, 45.1%) and 9 did not report harms at all (9 of 82, 10.9%). A significant relation was found between completeness of harms reporting and overall AMSTAR appraisal (P = .0261), as well as whether a harm was listed as a primary or secondary outcome (P = .0001). Eight SR dyads had corrected covered areas of 50% or greater and were compared for shared harms reported.

Conclusions

In this study, we found inadequate harms reporting in most SRs concerning hip arthroscopy.

Clinical Relevance

With the magnitude of hip arthroscopic procedures being performed, adequate reporting of harms-related information in the research surrounding this treatment is essential in assessing the efficacy of the treatment. This study provides data in relation to harms reporting in SRs regarding hip arthroscopy.

Conservative vs. Surgical Management for Femoro-Acetabular Impingement: A Systematic Review of Clinical Evidence

Femoro-acetabular impingement (FAI) syndrome is one of the most studied conditions in sports medicine. Surgical or conservative approaches can be proposed for treating FAI, although the best standard of care is not established yet. Our aim is to provide a comprehensive review of the best treatment for FAI syndrome evaluating differences in outcomes between surgical and non-operative management. A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases, using the following keywords: "femoroacetabular impingement", "FAI", in association with "surgery", "arthroscopy", "surgical" and "conservative", "physiotherapy", "physical therapy", "rehabilitation", "exercise". Only Level I RCTs were included. Four articles were selected for this systematic review. Our analysis showed different therapeutic protocols, follow-up periods, and outcomes; however, three out of the four studies included favored surgery. Our study demonstrates beneficial effects for both arthroscopic treatment and a proper regimen of physical therapy, nevertheless a surgical approach seemed to offer superior short-term results when compared to conservative care only. Further trials with larger sample sizes and longer follow-ups are needed to assess the definitive approach to the FAI condition.