Hip chondropathy at arthroscopy: prevalence and relationship to labral pathology, femoroacetabular impingement and patient-reported outcomes

Higher preoperative patient expectations predict better patient-reported psychosocial health outcomes after hip arthroscopy

Introduction

Preoperative expectations are a determinant of patient-reported outcomes (PROs) within several orthopaedic subspecialties. However, the impact on outcomes after hip arthroscopy is unclear. The aim of this study was to explore the relationship between preoperative patient expectations and PROs after hip arthroscopy.

Methods

Patients who underwent hip arthroscopy at a single institution were included. Patient expectations were measured preoperatively using the Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) expectations domain. Patient-Reported Outcomes Measurement Information System (PROMIS) domains, a numeric pain scale (NPS), and the Marx activity rating scale (MARS) were assessed 2 years postoperatively. Spearman's coefficient was used to assess the correlation between preoperative expectations and 2-year PROs. Linear regression was used to ascertain the effect of preoperative expectations on 2-year PROs.

Results

105 patients were included, and 78 (74 %) completed 2-year follow-up. The mean (SD) preoperative expectations score was 88.3 (15.3). Higher expectations correlated with better postoperative fatigue, anxiety, depression, pain, and activity levels, as well as more improvement in fatigue, pain, and activity. Expectations scores were higher for patients who achieved minimal clinically important difference (MCID) for PROMIS Fatigue (92.6 vs 82.0, p = .003) and MARS activity (95.3 vs 86.2, p = .014). When controlling for possible confounders, higher expectations independently predicted better postoperative PROMIS Fatigue (β = -0.26, SE = 7.23), Social Satisfaction (β = 0.24, SE = 0.09), and Anxiety (β = -0.24, SE = 0.08).

Conclusion

Higher preoperative expectations are an independent predictor of better psychosocial outcomes 2 years after hip arthroscopy. Setting positive expectations preoperatively may be important for enhancing psychosocial health postoperatively.

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.

The Relationship Between Tensor Fascia Latae and Gluteus Maximus Has the Potential to Indicate Early Intra-articular and Degenerative Pathologies of the Femoral-Acetabular Joint: A Narrative Review

Intra-articular and degenerative hip pathologies have become common place with the number of total hip replacements rising year on year in the United Kingdom (UK). Pathology is identified by clinicians using special tests which are researched maneuvers used by clinicians to rule in or rule out specific musculoskeletal pathologies. Special tests used for hip pathology usually have high specificity to exclude degenerative and intraarticular pathology but vary in sensitivity. These special tests are usually only conducted when a person is symptomatic and typically require radiological confirmation to diagnose. The aim of this review was to appraise research to determine whether functional changes in the TFL and UGM muscle complex could indicate degenerative and/or intra articular pathology, with a specific focus on the utility of the ratio in strength of TFL and UGM to assist clinical diagnosis. The hypothesis was that the ratio of the strength of Tensor Fascia Latae (TFL) and the upper fibres of Gluteus Maximus (UGM) could suggest early intra-articular hip pathology, and that changes to this ratio could indicate deterioration of the hip joint before symptoms present/progress.

Level of Evidence

5.

Female Sex Increases Susceptibility for the Negative Impacts of Advanced Age and Obesity on Patient-Reported Functional Outcomes 10 Years after Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

This study aims to evaluate patient-reported outcomes (PROs) and reoperation rates in patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) over a minimum 10-year follow-up stratified by sex, age, and body mass index (BMI).

METHODS

Primary hip arthroscopies performed for FAIS between 2010 and 2013, with a minimum 10-year follow-up, were reviewed. Procedures consisting of microfracture, or labral debridement without repair, were excluded. Ten-year PROs were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were categorized into three groups by age (<30, 30-44, >45 years) and BMI (<25.0, 25.0-29.9, ≥ 30). Minimum clinically important difference (MCID) was set to half the preoperative standard deviation of the cohort. Reoperation rates and PROs were compared, and regression analysis identified independent predictors of PROs.

RESULTS

At minimum 10-year follow-up (mean: 11.6 [10.0-13.9] years), 59.2% follow-up was achieved, representing 154 hips (141 patients). The cohort had a mean age of 38.5 years, BMI of 24.4, and was 68.2% female. At follow-up, 91.6% of the cohort achieved MCID with a 9.7% reoperation rate. In the middle-aged group, males had higher mHHS (mean: 92.8 vs 85.2; P = .015) and NAHS (mean: 91.6 vs 83.4; P = .008) scores compared to females. In the BMI ≥30 group, males had higher mHHS (mean: 83.3 vs 66.4; P = .030) and NAHS scores (mean: 83.0 vs 58.5; P = .035). Only 72.7% of females with BMI ≥30 achieved MCID for mHHS and NAHS, compared to BMI <25 (96.6% and 94.9%, respectively) and 25-29.9 (87.5% and 83.3%) (mHHS: P = .016; NAHS: P = .038). Similarly, 78.8% of females aged ≥45 achieved MCID for NAHS, compared to 92.9% of those aged <30 and 97.1% of those 30-44 (P = .040). Multivariable regression identified older age (mHHS: P = .019; NAHS: P = .042) and higher BMI (mHHS: P = .007; NAHS: P < .001) as independently predictive of worse 10-year PROs.

CONCLUSION

Older age and greater BMI independently predicted poorer long-term functional outcomes after hip arthroscopy for FAIS. Female sex, while not independently predictive, may make patients more susceptible to the negative effects of older age and BMI. No significant association was observed for reoperation rates.

LEVEL OF EVIDENCE

Level IV, retrospective therapeutic case series.

Asymptomatic female softball pitchers have altered hip morphology and cartilage composition

Few studies have explored hip morphology and cartilage composition in female athletes or the impact of asymmetric repetitive loading, such as occurs during softball pitching. The current cross-sectional study assessed bilateral bony hip morphology on computed tomography imaging in collegiate-level softball pitchers ('Pitch1', n = 25) and cross-country runners ('Run', n = 13). Magnetic resonance imaging was used to assess cartilage relaxation times in a second cohort of pitchers ('Pitch2', n = 10) and non-athletic controls ('Con', n = 4). Pitch1 had 52% greater maximum alpha angle than Run (p < 0.001) and were 21.3 (95% CI 2.4 to 192.0) times more likely to have an alpha angle ≥ 60° within at least one hip. Pitch2 had longer T2 relaxation times in the superior femoral cartilage of the drive leg (same side as the throwing arm) and stride leg than Con (all p < 0.02). The drive leg in Pitch2 had longer T1ρ and T2 relaxation times in the superior femoral cartilage compared to the stride leg (all p ≤ 0.03). Asymptomatic softball pitchers exhibit altered bony hip morphology and cartilage composition compared to cross-country runners and non-athletic controls, respectively. They also exhibit asymmetry in cartilage composition. Further studies with larger sample sizes are warranted and any potential long-term consequences of the changes in terms of symptom and osteoarthritis development requires investigation.

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.

Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

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.

A New Approach to Postoperative Rehabilitation following Mosaicplasty and Bone Marrow Aspiration Concentrate (BMAC) Augmentation

BACKGROUND

Chondral defects in the knee present a significant challenge due to their limited self-healing capacity, often leading to joint degeneration and functional disability. Current treatments, including surgical approaches like mosaicplasty and regenerative therapies such as bone marrow aspirate concentrate (BMAC) augmentation, aim to address these defects and improve patient outcomes.

MATERIALS AND METHODS

This study conducted a single-center, randomized controlled trial to evaluate the efficacy of different treatment approaches and rehabilitation protocols for chondral defects. Thirty-seven subjects presenting with symptomatic chondral or osteochondral defects (>3 cm2) in the weight-bearing region of the femoral condyle were partitioned into three groups, and underwent mosaicplasty with or without BMAC augmentation, followed by either a 6-week or 12-week rehabilitation program. Group 1 (n = 10) received mosaicplasty combined with BMAC augmentation and engaged in a twelve-week two-phase rehabilitation protocol. Group 2 (n = 15) underwent mosaicplasty alone and participated in the same twelve-week two-phase rehabilitation regimen. Meanwhile, Group 3 (n = 12) underwent mosaicplasty and underwent a shorter six-week one-phase rehabilitation program. Clinical assessments were performed using the visual analog scale (VAS) for pain, goniometry for the knee's range of motion (ROM), manual muscle testing (MMT) for quadricep strength, and the Western Ontario and McMaster University Arthritis Index (WOMAC) for functional evaluation in three test phases.

RESULTS

Significant differences in WOMAC scale scores were observed between the three groups at the intermediate (F(2, 34) = 5.24, p < 0.010) and final (F(2, 34) = 111, p < 0.000) stages, with post hoc Tukey tests revealing variations shared among all three groups. The between-group analysis of the VAS scale demonstrated no statistically significant difference initially (F(2, 34) = 0.18, p < 0.982), but significant differences emerged following the intermediate (F(2, 34) = 11.40, p < 0.000) and final assessments (F(2, 34) = 59.87, p < 0.000), with post hoc Tukey tests revealing specific group variations, notably between Group 1 and both Group 2 and Group 3, and also between Group 3 and Group 2. The between-group analysis of quadricep muscle strength using MMT scores revealed no statistically significant differences initially (F(2, 34) = 0.376, p < 0.689) or following the intermediate assessment (F(2, 34) = 2.090, p < 0.139). The one-way ANOVA analysis showed no significant difference in the knee ROM initially (F(2, 34) = 1.037, p < 0.366), but significant differences emerged following intermediate (F(2, 34) = 9.38, p < 0.001) and final assessments (F(2, 34) = 11.60, p < 0.000). Post hoc Tukey tests revealed significant differences between Groups 1 and 2, Groups 1 and 3, and Groups 2 and 3 at intermediate and final assessments.

CONCLUSIONS

The patients who received BMAC augmentation and completed a 12-week rehabilitation protocol had significantly better outcomes in pain relief, knee function, and ROM when compared to those who did not receive BMAC augmentation or those who completed a shorter rehabilitation period. Our findings suggest that combining mosaicplasty with BMAC augmentation and a comprehensive rehabilitation program can lead to superior clinical outcomes for patients with chondral defects in the knee.

Management of chondral and osteochondral lesions of the hip : A comprehensive review

Chondral and osteochondral lesions encompass several acute or chronic defects of the articular cartilage and/or subchondral bone. These lesions can result from several different diseases and injuries, including osteochondritis dissecans, osteochondral defects, osteochondral fractures, subchondral bone osteonecrosis, and insufficiency fractures. As the cartilage has a low capacity for regeneration and self-repair, these lesions can progress to osteoarthritis. This study provides a comprehensive overview of the subject matter that it covers. PubMed, Scopus and Google Scholar were accessed using the following keywords: "chondral lesions/defects of the femoral head", "chondral/cartilage lesions/defects of the acetabulum", "chondral/cartilage lesions/defects of the hip", "osteochondral lesions of the femoral head", "osteochondral lesions of the acetabulum", "osteochondral lesions of the hip", "osteochondritis dissecans," "early osteoarthritis of the hip," and "early stage avascular necrosis". Hip osteochondral injuries can cause significant damage to the articular surface and diminish the quality of life. It can be difficult to treat such injuries, especially in patients who are young and active. Several methods are used to treat chondral and osteochondral injuries of the hip, such as mesenchymal stem cells and cell-based treatment, surgical repair, and microfractures. Realignment of bony anatomy may also be necessary for optimal outcomes. Despite several treatments being successful, there is a lack of head-to-head comparisons and large sample size studies in the current literature. Additional research will be required to provide appropriate clinical recommendations for treating chondral/osteochondral injuries of the hip joint.

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Methods

A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected.

Results

A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015).

Conclusion

There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.

Criteria-Based Rehabilitation Following Revision Hip Arthroscopy: A Clinical Commentary

Hip revision arthroscopy is becoming an increasingly popular surgery for those with unsatisfactory outcomes following primary hip arthroscopy. With the relatively uncommon but potentially increased difficulty of rehabilitation from this surgery, a lack of established research regarding rehabilitative programs remains. Therefore, the purpose of this clinical commentary is to propose a criterion-based progression that considers the intricacies present following a hip revision arthroscopy from early rehabilitation through return to sport. Criteria are presented clearly to promote objective progression through rehabilitation as opposed to relying on time since surgery as revision surgeries do not always follow traditional tissue healing time-frames. This criterion based progression promotes range of motion (ROM), strength, gait, neuromuscular control, load introduction and gradual return to play.

Level of Evidence

5.

Imaging of Cartilage and Chondral Defects: An Overview

A healthy articular cartilage is paramount to joint function. Cartilage defects, whether acute or chronic, are a significant source of morbidity. This review summarizes various imaging modalities used for cartilage assessment. While radiographs are insensitive, they are still widely used to indirectly assess cartilage. Ultrasound has shown promise in the detection of cartilage defects, but its efficacy is limited in many joints due to inadequate visualization. CT arthrography has the potential to assess internal derangements of joints along with cartilage, especially in patients with contraindications to MRI. MRI remains the favored imaging modality to assess cartilage. The conventional imaging techniques are able to assess cartilage abnormalities when cartilage is already damaged. The newer imaging techniques are thus targeted at detecting biochemical and structural changes in cartilage before an actual visible irreversible loss. These include, but are not limited to, T2 and T2* mapping, dGEMRI, T1ρ imaging, gagCEST imaging, sodium MRI and integrated PET with MRI. A brief discussion of the advances in the surgical management of cartilage defects and post-operative imaging assessment is also included.

Gluteal activation during squatting reduces acetabular contact pressure in persons with femoroacetabular impingement syndrome: A patient-specific finite element analysis

BACKGROUND

Femoroacetabular impingement syndrome is a motion-related clinical disorder resulting from abnormal hip joint morphology. Mechanical impingement, in which the aspherical femoral head (cam morphology) abuts with the acetabular rim, is created with simultaneous hip flexion, internal rotation, and adduction. Impaired function of the gluteal muscles may be contributory to femoroacetabular impingement syndrome progression. The purpose of this study was to assess the influence of gluteal muscle recruitment on acetabular contact pressure during squatting in persons with cam femoroacetabular impingement syndrome.

METHODS

Eight individuals (4 males, 4 females) with a diagnosis of cam femoroacetabular impingement syndrome underwent CT imaging of the pelvis and proximal femora, and a biomechanical assessment of squatting (kinematics, kinetics, and electromyography). Two maximal depth bodyweight squat conditions were evaluated: 1) non-cued squatting; and 2) cued gluteal activation squatting. Utilizing subject-specific electromyography-driven hip and finite element modeling approaches, hip muscle activation, kinematics, bone-on-bone contact forces, and peak acetabular contact pressure were compared between squat conditions.

FINDINGS

Modest increases in gluteus maximus (7% MVIC, P < 0.0001) and medius (6% MVIC, P = 0.009) activation were able to reduce hip internal rotation on average 5° (P = 0.024), and in doing so reduced acetabular contact pressure by 32% (P = 0.023). Reductions in acetabular contact pressure occurred despite no change in hip abduction and increased bone-on-bone contact forces occurring in the cued gluteal activation condition.

INTERPRETATION

Our findings highlight the importance of gluteal activation in minimizing mechanical impingement and provide a foundation for interventions aimed at preventing the development and progression of femoroacetabular impingement syndrome.

Arthroscopic Treatment for Femoroacetabular Impingement Syndrome in Adolescents: A Systematic Review and Meta-Analysis

OBJECTIVE

The objective of this review was to analyze the effect of arthroscopic surgery for femoroacetabular impingement syndrome (FAI) in adolescents and factors that may influence the revision rate.

DESIGN

Systematic review and meta-analysis.

SETTING

PubMed, Scopus, Cochrane Library, EMBASE, and MEDLINE were searched from their earliest records to May 2021.

PATIENTS

Adolescents who underwent primary arthroscopic treatment for FAI.

INTERVENTIONS

Hip arthroscopic treatment.

MAIN OUTCOME MEASURES

Patient-reported outcomes (PROs), alpha angle, revision rates, and the rate of complications.

RESULTS

A total of 832 hips in 753 patients were included in this study. All PROs improved significantly. The modified Harris Hip Score pooled mean difference was 24.99 (95% CI, 22.88-27.10, P < 0.0001, I2 = 19.9%), Hip Outcome Score (HOS)-Sports-Specific Subscale was 35.88 (95% CI, 33.07-38.68, P < 0.0001, I2 = 0%), HOS-Activities of Daily Living was 23.53 (95% CI, 21.21-25.85, P < 0.0001, I2 = 0%), and the Nonarthritic Hip Score was 22.34 (95% CI, 18.40-26.28, P < 0.0001, I2 = 40.9%). The visual analog scale for pain decreased by 40.39 (44.39-36.40, P < 0.0001, I2 = 0%). The alpha angle decreased by 22.0 degrees from 62.9 degrees to 40.9 degrees after arthroscopic surgery. The rate of complication and revision surgery was 1.2% (10/832) and 3.4% (28/832), respectively, with high postoperative patient satisfaction.

CONCLUSIONS

All PROs significantly improved after surgery, with a low rate of complications and reoperation. High postoperative patient satisfaction was also reported.

Does Femoroacetabular Impingement Syndrome Affect Self-Reported Burden in Football Players With Hip and Groin Pain?

BACKGROUND

It is unknown if football players with femoroacetabular impingement (FAI) syndrome report worse burden than those with other causes of hip/groin pain, and to what extent this is mediated by cartilage defects and labral tears.

HYPOTHESIS

Football players with FAI syndrome would report worse burden than other symptomatic players, with the effect partially mediated by cartilage defects and/or labral tears.

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

Football (soccer and Australian football) players (n = 165; 35 women) with hip/groin pain (≥6 months and positive flexion-adduction-internal rotation test) were recruited. Participants completed 2 patient-reported outcome measures (PROMs; the International Hip Outcome Tool-33 [iHOT-33] and Copenhagen Hip and Groin Outcome Score [HAGOS]) and underwent hip radiographs and magnetic resonance imaging (MRI). FAI syndrome was determined to be present when cam and/or pincer morphology were present. Cartilage defects and labral tears were graded as present or absent using MRI. Linear regression models investigated relationships between FAI syndrome (dichotomous independent variable) and PROM scores (dependent variables). Mediation analyses investigated the effect of cartilage defects and labral tears on these relationships.

RESULTS

FAI syndrome was not related to PROM scores (unadjusted b values ranged from -4.693 (P = 0.23) to 0.337 (P = 0.93)) and cartilage defects and/or labral tears did not mediate its effect (P = 0.22-0.97).

CONCLUSION

Football players with FAI syndrome did not report worse burden than those with other causes of hip/groin pain. Cartilage defects and/or labral tears did not explain the effect of FAI syndrome on reported burden.

CLINICAL RELEVANCE

FAI syndrome, cartilage defects, and labral tears were prevalent but unrelated to reported burden in symptomatic football players.

Isolated Gluteus Maximus Tear of a Middle-Aged Fitness Coach; A Case Report

Background: Injuries of the hip extensors are not uncommon, with those of the hamstrings being frequent among athletes. On the contrary, isolated injuries of the gluteus maximus muscle have been barely reported in the literature. Case Report: We present a case of a 63-year-old male water aerobics trainer with an acute tear of the right gluteus maximus tendon and describe the clinical presentation, imaging studies, surgical treatment, and functional outcome one year after surgery.

Relationship between cam morphology, hip symptoms, and hip osteoarthritis: the Musculoskeletal pain in Ullersaker STudy (MUST) cohort

BACKGROUND

The primary aim of this study was to determine the prevalence of cam morphology in a cohort of people aged 40-55 years. Secondary aims were to: (1) determine differences in participant characteristics, physical impairments, radiographic and ultrasound appearances of people with and without cam morphology; and (2) explore associations between cam morphology and radiographic measures of hip osteoarthritis (OA).

METHODS

107 people (68% women; 49 ± 4 years) from the Musculoskeletal pain in Ullensaker (MUST) Study underwent the clinical and imaging examinations. Examinations included questionnaires, hip range, functional task performance, pelvic radiographs and ultrasound. Alpha angle and radiographic hip OA (Kellgren Lawrence (KL) and minimal joint space (MJS)) were determined.

RESULTS

The prevalence of cam morphology was 42% and was bilateral in 47%. People with cam morphology were 6 times more likely to have a KL score ⩾2 (adjusted odds ratio [95% confidence intervals, p-value]) 6.386 [1.582-37.646, p = 0.012]) and 4 times more likely to have MJS <2.0 mm (adjusted odds ratio 4.032 [1.031-12.639, p = 0.045]). The prevalence of radiographic OA features ranged from 4-13% in people with cam morphology, and 0-3% in those without. Those with cam morphology also demonstrated reduced hip flexion and rotation range (p = 0.018-0.036) compared with those without. There was no association between ultrasonic features and patient reported outcomes, and cam morphology.

CONCLUSIONS

In a cohort aged 40-55 years, the prevalence of cam morphology was high (42%), with a significant relationship between cam morphology and radiographic measures of hip OA. Further longitudinal studies should explore the relationship between cam morphology and hip OA in younger people.

Movement Patterns and Their Associations With Pain, Function, and Hip Morphology in Individuals With Femoroacetabular Impingement Syndrome: A Scoping Review

OBJECTIVE

The purpose of the study was to synthesize studies of movement patterns and their association with hip pain, function/activity, and morphology in individuals with femoroacetabular impingement syndrome (FAIS).

METHODS

PubMed, SPORTDiscus, CINAHL, Embase, and Scopus databases were searched using predefined terms. Two authors independently reviewed abstracts and full texts. Studies were included if they enrolled individuals with FAIS, reported kinematic or kinetic data during movement tasks, and tested the data's associations with hip pain, function/activity, or morphology. Exclusion criteria were studies that did not evaluate associations between movement patters and pain, function/activity, or hip morphology. Additionally, studies with hip conditions other than FAIS, case reports, conference proceedings, review articles, and non-English studies were excluded. Descriptive consolidation and qualitative synthesis were performed for the included studies.

RESULTS

Of the 1155 potential studies, 5 studies met all eligibility criteria. Movement patterns were evaluated during walking (n = 4) and squatting (n = 1). Studies reported multiple associations between variables of interest. Statistically significant associations were identified between movement patterns and hip pain (n = 2), function/activity (n = 2), or morphology (n = 3). Significant associations included increased hip flexion moment impulse during walking was associated with worse pain, increased hip flexion moment during walking was associated with worse hip function, decreased hip external rotation during gait and hip internal rotation during squat were associated with larger cam deformity, and increased hip flexion moment impulse during walking was also associated with more severe acetabular cartilage abnormalities.

CONCLUSIONS

Very little current evidence has evaluated the associations between altered movement patterns and hip pain, function/activity, or morphology in individuals with FAIS, and only low-intensity tasks have been tested. These studies found some preliminary associations between altered hip biomechanics and higher hip pain, worse hip function, and specific measures of hip morphology in individuals with FAIS.

IMPACT

This review is a first step in gaining a better understanding of movement patterns and their associations with hip pain, function/activity, and morphology, which could ultimately assist with the development of movement retraining interventions and potentially improve rehabilitation outcomes for those with FAIS.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

Acute and sub-acute changes in dynamic postural control following hip arthroscopy and post-operative rehabilitation."

CONTEXT

Hip pain is associated with impairments in postural control and balance. The Star Excursion Balance Test (SEBT) is a reliable and valid method to measure dynamic postural control.

OBJECTIVE

Examine changes to dynamic postural control following hip arthroscopy and subsequent rehabilitation from pre-surgery to three and six months post arthroscopy.

SETTING

Sixty-seven individuals (47 men) scheduled for hip arthroscopy to address chondrolabral pathology were matched with sixty-seven healthy controls. The hip pain group underwent post-operative rehabilitation including SEBT training.

MAIN OUTCOME MEASURES

SEBT reach normalized to limb length was collected pre-surgery and at three and six months post surgery, and compared with healthy matched controls. Repeated measure analysis of variance (ANOVA) evaluated whether SEBT reach differed between the three time points and t-tests were used to evaluate between-limb and between-group differences.

RESULTS

Pre-surgical SEBT reach was significantly less than the control group in all directions (p<0.001). At three months post surgery, SEBT reach significantly increased in the posterior-lateral (PL) (p<0.001), anterior-lateral (AL) (p<0.001) and posterior-medial (PM) (p=0.006) directions from pre-surgery. At six months post surgery, all directions of reach had significantly increased (p<0.001) from baseline. Compared to the control group, AL (-2.5 %, p=0.038), anterior medial (AM) (-2.9%, p=0.019) and posterior-medial (PM) (-5.2%, p= 0.002) reach remained significantly less at six months post surgery. No significant difference existed between the control and surgical groups for reach in the PL (-3.6%, p=0.061) direction.

CONCLUSIONS

Pre-surgical dynamic balance control within a hip pain group was significantly poorer than matched controls as measured by the SEBT. At three months post hip arthroscopy, there were significant improvements in dynamic balance in the PM, PL and AL SEBT directions. By six months post surgery, all directions of SEBT reach had significantly improved but only PL reach improved to the level of healthy controls.

Femoroacetabular impingement: correlation between imaging parameters, sport activity, and chondral damage

BACKGROUND

Femoroacetabular impingement is characterised by an abnormal contact between the acetabulum and the femoral head-neck junction. Femoroacetabular impingement shows three main clinical frameworks: Pincer-FAI, Cam-FAI and Cam-Pincer mixed form. The aim of the study was to investigate the correlation between femoroacetabular impingement, imaging, activity and chondral damages.

METHODS

Forty-one patients, undergoing arthroscopic chondroartroplasty for Cam and Cam-Pincer mixed form were considered. All patients underwent an X-ray hip evaluation (G1 group), while 15 patients also underwent a pelvis MRI evaluation (G2 subgroup). For G1 patients, the superior-inferior offset ratio and alpha angle were calculated from the X-ray examinations. For G2 patients, the antero-posterior offset ratio was also calculated from pelvis MRI. Chondral damage was classified according to the Outerbridge classification.

RESULTS

The superior-inferior offset ratio and the antero-posterior offset ratio were respectively 0.50 ± 0.23 and 0.33 ± 0.19. The α angle predictive for a chondral damage of IV degree was 81.5°.The chondral damage of the patients suffering from Cam-FAI and Cam-Pincer mixed form were respectively 3.53±0.80 and 3.00±1.41.

CONCLUSIONS

From the results was possible to: - Elaborate two tables providing a reliable indirect calculation of the alpha angle. - Establish an alpha angle cut-off value indicative for a IV degree chondral damage. - Show that Pincer-FAI does not represent an aggravating factor for chondral damage - Show that the level of sports activity was related to the severity of chondral damage. - Show that a physically demanding occupation was not an aggravating factor for chondral damage.

Association between severity of hip chondrolabral injuries, dynamic hip muscle strength and quality of life: A cross-sectional study in patients with femoroacetabular impingement syndrome scheduled for hip arthroscopy

BACKGROUND

We assessed the association between: the severity of hip chondral or labral pathology with dynamic hip muscle strength or quality of life in patients with femoroacetabular impingement syndrome scheduled for hip arthroscopy. We also assessed the association between dynamic hip muscle strength with quality of life.

METHODS

Eighty-three participants with femoroacetabular impingement syndrome scheduled for hip arthroscopy were included. We measured dynamic hip abduction and adduction muscle strength with an isokinetic dynamometer (Nm/kg), and quality of life with the iHoT-33 questionnaire. The severity of hip chondrolabral pathologies was scored using the modified Beck classification. Linear regression analyses were conducted to assess the association between severity of hip chondral or labral pathology with dynamic hip muscle strength and quality of life.

FINDINGS

The regression analyses showed no association between the (i) severity of hip chondral (adjusted r²: 0.14) or labral (adjusted r²: 0.08) pathology and quality of life (P > 0.05), (ii) between the severity of hip chondral or labral pathology and dynamic hip abduction and adduction muscle strength (P > 0.05). Significant correlation was observed for quality of life and hip abduction (adjusted r²:0.29; P < 0.001) or adduction (adjusted r²: 0.32; P < 0.001) muscle strength.

INTERPRETATION

The severity of hip chondral or labral pathologies were not associated with quality of life or dynamic hip muscle strength in participants with femoroacetabular impingement syndrome. Greater dynamic hip abduction and adduction muscle strength were associated with better quality of life in participants with femoroacetabular impingement syndrome scheduled for hip arthroscopy.

Lower-limb work during high- and low-impact activities in hip-related pain: Associations with sex and symptom severity

BACKGROUND

Hip-related pain (HRP) is described as a movement-related disorder. However, little attention is given to the way people with HRP move, especially in populations still participating in sport. Thus, limiting our understanding of movementbased impairments in HRP and their potential relationships with pain/symptoms.

RESEARCH QUESTION

(1) What are the differences in absolute and relative amounts of positive and negative lower-limb joint work during walking and the single-leg drop jump (SLDJ) in football players with and without HRP? (2) What are the relationships between lower-limb joint work and HRP burden?

METHODS

88 football players with HRP and 30 control football players were recruited. Positive and negative work done by the hip, knee, and ankle (and each joint's relative contribution to total work done) were calculated. The effect of sex on the relationship between HRP and work done, as well as the association between work done and International Hip Outcome Tool (iHOT33) scores, were assessed using linear and beta regressions models.

RESULTS

Walking: No joint work variables were significantly different between groups, nor were any relationships with iHOT33 scores evident. SLDJ: The knee's relative contribution to total lower-limb negative work done was 37.7 % and 42.4 % for women with and without HRP, respectively (P = 0.04). The iHOT33 was significantly associated with positive (P = 0.03 to <0.01) and negative (P = 0.02 to <0.01) work done by the hip as well as negative work done by the ankle (P = 0.03 to 0.01), independent of sex.

SIGNIFICANCE

Only one significant between-group comparison was revealed, involving the knee in female football players. In addition, football players with a greater selfreported burden of HRP tended to display lower hip joint work during the SLDJ. Rehabilitation programs could be targeted to address these impairments and normalize work done during high impact tasks in the management of HRP.

Improving function in people with hip-related pain: a systematic review and meta-analysis of physiotherapist-led interventions for hip-related pain

OBJECTIVE

To report the effectiveness of physiotherapist-led interventions in improving pain and function in young and middle-aged adults with hip-related pain.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A comprehensive, reproducible search strategy was performed on five databases in May 2019. Reference lists and grey literature were also searched.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Population: people aged ≥18 years with hip-related pain (with or without a diagnosis of femoroacetabular impingement syndrome).

INTERVENTION(S)

physiotherapist-led interventions for hip pain. Comparators: sham treatment, no treatment or other treatment (eg, hip arthroscopic surgery).

OUTCOMES

primary outcomes included patient-reported hip pain and function. Secondary outcomes included physical function measures.

RESULTS

1722 papers were identified. After exclusion criteria were applied, 14 studies were included for analysis. They had varied risk of bias. There were no full-scale placebo-controlled randomised controlled trials (RCTs) of physiotherapist-led treatment. Pooled effects ranged from moderate effects (0.67 (95% CI 0.07 to 1.26)) favouring physiotherapist-led intervention over no treatment post-arthroscopy, to weak effects (-0.32 (95% CI 0.57 to 0.07)) favouring hip arthroscopy over physiotherapist-led treatment.

CONCLUSION

Physiotherapist-led interventions might improve pain and function in young and middle-aged adults with hip-related pain, however full-scale high-quality RCT studies are required.

PROSPERO REGISTRATION NUMBER

CRD42018089088.

Patient-related risk factors associated with less favourable outcomes following hip arthroscopy

AIMS

This paper aims to review the evidence for patient-related factors associated with less favourable outcomes following hip arthroscopy.

METHODS

Literature reporting on preoperative patient-related risk factors and outcomes following hip arthroscopy were systematically identified from a computer-assisted literature search of Pubmed (Medline), Embase, and Cochrane Library using Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and a scoping review.

RESULTS

Assessment of these texts yielded 101 final articles involving 90,315 hips for qualitative analysis. The most frequently reported risk factor related to a less favourable outcome after hip arthroscopy was older age and preoperative osteoarthritis of the hip. This was followed by female sex and patients who have low preoperative clinical scores, severe hip dysplasia, altered hip morphology (excess acetabular retroversion or excess femoral anteversion or retroversion), or a large cam deformity. Patients receiving workers' compensation or with rheumatoid arthritis were also more likely to have a less favourable outcome after hip arthroscopy. There is evidence that obesity, smoking, drinking alcohol, and a history of mental illness may be associated with marginally less favourable outcomes after hip arthroscopy. Athletes (except for ice hockey players) enjoy a more rapid recovery after hip arthroscopy than non-athletes. Finally, patients who have a favourable response to local anaesthetic are more likely to have a favourable outcome after hip arthroscopy.

CONCLUSION

Certain patient-related risk factors are associated with less favourable outcomes following hip arthroscopy. Understanding these risk factors will allow the appropriate surgical indications for hip arthroscopy to be further refined and help patients to comprehend their individual risk profile. Cite this article: Bone Joint J 2020;102-B(7):822-831.

Meta-Analysis of the Surgical and Rehabilitative Outcomes of Hip Arthroscopy in Athletes With Femoroacetabular Impingement

OBJECTIVES

Femoroacetabular impingement (FAI) poses a threat to athletes' capacity to compete. This review aims to estimate the rate of return to sport after hip arthroscopy for treatment of FAI as well as identify factors that may affect athletes' outcomes.

DESIGN

Meta-analysis.

METHODS

Four databases (EMBASE, PubMed, Web of Science, and Cochrane) were searched in July 2015 by 2 reviewers. Studies were required to include athletes who were treated with hip arthroscopy for symptomatic FAI and also report return to sport as an outcome. A validated tool was used for quality assessment and level of agreement between raters was calculated. A meta-analysis for proportions returning to sport was performed on the available data using MedCalc software. Additional outcomes were descriptively analyzed.

RESULTS

A total of 15 case series involving 823 patients were included in the review, with moderate to high methodological quality. 88.3% [95% confidence interval (CI), 83.4%-92.4%] of athletes returned to sport after arthroscopy and 85.3% (95% CI, 77.6%-91.6%) returned to preinjury level. All outcome measures used reported measurable improvements. Complication rates were low.

CONCLUSIONS

The majority of athletes return to sport after hip arthroscopy for symptomatic FAI. Severity of intraarticular damage and degree of degenerative changes affect ability to return to sport. Additional validated outcome measures should be used together with return to sport. Future studies should be prospective with longer-term follow-up to provide a higher level of evidence for outcomes.

Mid-term Patient-reported Outcomes of Hip Arthroplasty After Previous Hip Arthroscopy: A Matched Case-control Study With a Minimum 5-year Follow-up

BACKGROUND

Previous hip arthroscopy may affect the outcomes of subsequent hip arthroplasty. The purpose is to compare mid-term patient-reported outcomes (PROs) and complication rates in patients who had previous ipsilateral hip arthroscopy (PA) with those without a previous surgery.

METHODS

A minimum 5-year PROs, complications, and revision surgery rates were compared between total hip arthroplasty (THA) recipients who received PA and those without. Available intraoperative findings, procedures, and conversion time of arthroscopies were reported. The relative risk (RR) of complications and revision THAs were reported. A Kaplan-Meier analysis assessed survivorship of revision THA.

RESULTS

There were 34 cases (33 patients) of PA that were matched to 89 control cases (87 patients). Both cohorts reported similar scores for Harris hip score, Forgotten Joint Score, pain, and patient satisfaction. No differences in the outcomes were found based on the arthroplasty approach. A higher postoperative complication rate {RR, 2.617 (95% confidence interval [CI], 0.808 to 8.476)} and revision THA rate (RR, 13.088 [95% CI, 1.59 to 107.99]) were found in the PA group.

CONCLUSION

Patients with PA demonstrated similar levels of PROs as those without previous ipsilateral hip arthroscopy. There may, however, be a higher rate of complications and revision surgery in the PA group.

LEVEL OF EVIDENCE

III.

Pathomechanics Underlying Femoroacetabular Impingement Syndrome: Theoretical Framework to Inform Clinical Practice

Over the last decade, there has been a marked increase in attention to, and interest in, femoroacetabular impingement syndrome (FAIS). Despite continued efforts by researchers and clinicians, the development, progression, and appropriate treatment of FAIS remains unclear. While research across various disciplines has provided informative work in various areas related to FAIS, the underlying pathomechanics, time history, and interaction between known risk factors and symptoms remain poorly understood. The purpose of this perspective is to propose a theoretical framework that describes a potential pathway for the development and progression of FAIS. This paper aims to integrate relevant knowledge and understanding from the growing literature related to FAIS to provide a perspective that can inform future research and intervention efforts.

Hip muscle atrophy in patients with acetabular labral joint pathology

Intra-articular hip joint pathology is a source of hip and groin pain in active individuals and is thought to be a precursor to hip osteoarthritis. Limited evidence exists to guide appropriate physiotherapy management for these patients. Identification of which hip muscles are affected may help clinicians to develop effective exercise programs. A cross-sectional observational study in a hospital setting was conducted to investigate the size of individual hip abductor, hip extensor, and hip external rotator muscles in patients with acetabular labral joint pathology compared with age and sex matched healthy subjects. Twelve participants (eight females, four males), aged 20-53 years, with a medical diagnosis of unilateral acetabular labral tear and 12 healthy participants were recruited. Magnetic resonance imaging was used to assess cross-sectional areas of the gluteus minimus, gluteus medius, upper gluteus maximus, lower gluteus maximus, piriformis, and quadratus femoris muscles bilaterally. Gluteus medius muscle cross-sectional area was significantly different between groups (P < 0.01, effect size = 0.92) with muscle size found to be smaller in the pathology group. No differences were found for the other hip muscles (P > 0.05). These findings suggest that hip muscles are not all affected equally by the presence of intra-articular hip joint pathology. Atrophy of specific hip muscles, which are important in hip joint and pelvic stability, may alter hip joint function during gait and functional tasks. Clinicians treating patients with intra-articular hip joint pathology may need to prescribe exercises targeting the specific muscles with demonstrated dysfunction. Clin. Anat. 33:538-544, 2020. © 2019 Wiley Periodicals, Inc.

Altered gait mechanics are associated with severity of chondropathy after hip arthroscopy for femoroacetabular impingement syndrome

BACKGROUND

Suboptimal patient-reported function and movement impairments often persist after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Individuals with FAIS with preoperative cartilage pathology (ie. chondropathy) demonstrate distinct movement patterns and have worse post-operative outcomes. It is unknown whether the presence of chondropathy after surgery negatively affects movement and function.

RESEARCH QUESTION

Do sagittal plane gait mechanics differ based on chondropathy severity following arthroscopy for FAIS?

METHODS

A cross-sectional walking gait analysis was performed for 25 participants post-arthroscopy (2.48 ± 1.38y) and 12 healthy controls (HCs). Peak total support moment (TSM) and relative contributions of the hip, knee, and ankle were calculated during loading response. The Hip Osteoarthritis MRI Scoring System was used to categorize the FAIS group into no-mild or moderate-severe chondropathy groups based on 3 T magnetic resonance imaging of their surgical hip. The interactions of group by limb were evaluated for kinetic variables, covaried by gait speed.

RESULTS

Groups did not differ based on age, BMI and sex distribution (P ≥ 0.14). 13 participants with FAIS presented with moderate-severe chondropathy and 12 presented with no-mild chondropathy. Participants with moderate-severe chondropathy walked significantly slower than both other groups (P = 0.006) and demonstrated lower peak TSM than those with no-mild chondropathy (P = 0.002). Participants with no-mild chondropathy demonstrated lower hip (61.5 %) and greater ankle (17.7 %) contributions to the TSM on the involved limb compared to the moderate-severe group (hip:73.4 %, P = 0.07; ankle:10.5 %, P = 0.007).

SIGNIFICANCE

Slower gait speed alone did not explain the lower TSM strategy in participants with moderate-severe chondropathy. Interestingly, the joint contribution strategy of this group was not different than HCs. Participants with no-mild chondropathy demonstrated a TSM strategy that shifted the demand away from their hip and toward their ankle. Given the small sample size, and large variability in joint strategies, future work needs to examine whether these alterations in gait strategy, with or without advanced chondropathy, impact patient function.

Post-Treatment Classification for Acetabular Chondral Lesions in Hip Arthroscopy

Objective  To describe a postarthroscopic treatment classification system for acetabular chondral damage in the hip and to report the intraobserver and interobserver reliability of such classification. Methods  This is a retrospective review of ninety-nine digital video recordings made during arthroscopic surgery. Patients who underwent arthroscopic treatment for femoroacetabular impingement and evaluated at the hip arthroscopy outpatient clinic between March 2015 and March 2016 were included in the study. Patients with a history of previous hip surgery, radiologic evidence of advanced osteoarthritis (Tönnis grade > 2), who underwent labral resection, or whose digital recordings were incomplete or of insufficient quality for adequate review were excluded. Two orthopedic surgeons, who did not participate in the surgery, independently reviewed the video recordings and classified the remaining acetabular cartilage using the post-treatment classification system. Intraobserver and interobserver analysis was then conducted using intraclass correlation coefficient (ICC). Results  Excellent intraobserver reliability (ICC = 0.790; p  < 0.001) and interobserver reliability (ICC = 0.882; p  < 0.001) were observed. Both ICC values were statistically significant. Conclusion  The posttreatment classification of the remaining acetabular cartilage has excellent intra and interobserver reliability.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Consensus recommendations on the classification, definition and diagnostic criteria of hip-related pain in young and middle-aged active adults from the International Hip-related Pain Research Network, Zurich 2018

There is no agreement on how to classify, define or diagnose hip-related pain-a common cause of hip and groin pain in young and middle-aged active adults. This complicates the work of clinicians and researchers. The International Hip-related Pain Research Network consensus group met in November 2018 in Zurich aiming to make recommendations on how to classify, define and diagnose hip disease in young and middle-aged active adults with hip-related pain as the main symptom. Prior to the meeting we performed a scoping review of electronic databases in June 2018 to determine the definition, epidemiology and diagnosis of hip conditions in young and middle-aged active adults presenting with hip-related pain. We developed and presented evidence-based statements for these to a panel of 37 experts for discussion and consensus agreement. Both non-musculoskeletal and serious hip pathological conditions (eg, tumours, infections, stress fractures, slipped capital femoral epiphysis), as well as competing musculoskeletal conditions (eg, lumbar spine) should be excluded when diagnosing hip-related pain in young and middle-aged active adults. The most common hip conditions in young and middle-aged active adults presenting with hip-related pain are: (1) femoroacetabular impingement (FAI) syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without a distinct osseous morphology (labral, chondral and/or ligamentum teres conditions), and that these terms are used in research and clinical practice. Clinical examination and diagnostic imaging have limited diagnostic utility; a comprehensive approach is therefore essential. A negative flexion-adduction-internal rotation test helps rule out hip-related pain although its clinical utility is limited. Anteroposterior pelvis and lateral femoral head-neck radiographs are the initial diagnostic imaging of choice-advanced imaging should be performed only when requiring additional detail of bony or soft-tissue morphology (eg, for definitive diagnosis, research setting or when planning surgery). We recommend clear, detailed and consistent methodology of bony morphology outcome measures (definition, measurement and statistical reporting) in research. Future research on conditions with hip-related pain as the main symptom should include high-quality prospective studies on aetiology and prognosis. The most common hip conditions in active adults presenting with hip-related pain are: (1) FAI syndrome, (2) acetabular dysplasia and/or hip instability and (3) other conditions without distinct osseous morphology including labral, chondral and/or ligamentum teres conditions. The last category should not be confused with the incidental imaging findings of labral, chondral and/or ligamentum teres pathology in asymptomatic people. Future research should refine our current recommendations by determining the clinical utility of clinical examination and diagnostic imaging in prospective studies.

Combining results from hip impingement and range of motion tests can increase diagnostic accuracy in patients with FAI syndrome

PURPOSE

Clinical examination is an important part in the diagnosis of femoroacetabular impingement (FAI) syndrome. However, knowledge on reliability and validity of clinical diagnostic tests is scarce. The aims were to evaluate the inter-rater agreement and diagnostic accuracy of clinical tests to detect patients with FAI syndrome.

METHODS

Eighty-one patients (49% women) were recruited. Two experienced raters performed impingement and range of motion (ROM) tests. Three criteria had to be fulfilled for the diagnosis of FAI syndrome: (1) symptoms; (2) CAM and/or Pincer morphology; and (3) being responder to intra-articular block injection. For inter-rater agreement, the Cohen's kappa statistics were used (0.41-0.60 = moderate, 0.61-0.80 = substantial agreement). For diagnostic accuracy, sensitivity, specificity, positive and negative predictive values were calculated.

RESULTS

Anterior impingement test (AIMT), FADIR test and FABER test showed kappa values above 0.6. All passive hip ROM, except extension, had kappa values above 0.4. AIMT and FADIR showed the highest sensitivity, i.e., 80%, with a specificity of 26% and 25%, respectively. Passive hip ROM in internal rotation with neutral hip position had a sensitivity of 29% and a specificity of 94%.

CONCLUSION

The AIMT, FADIR and FABER tests were reliable between two experienced raters, while results from different raters for hip ROM should be interpreted with caution. The AIMT and FADIR test can only be used to rule out patients with FAI syndrome, while evaluation of ROM in internal rotation with neutral position may be more suitable to rule in patients with FAI syndrome.

LEVEL OF EVIDENCE

II.

Editorial Commentary: A Commentary on a Meta-analysis of Short-Term Outcomes

Hip pain is prevalent and costly, and young patients with hip femoroacetabular impingement have similar levels of pain and quality of life to older patients with hip osteoarthritis. Hip arthroscopic surgery for femoroacetabular impingement is increasing in prevalence, and the benefits of operative treatment compared with nonoperative treatment require consideration. Hip arthroscopy should not be a first-line treatment but can be necessary in cases in which high-quality, exercise-based nonsurgical treatment options have been exhausted. Patients should be informed that surgery is not necessarily cost-effective and may have an increased risk of comorbidities such as chronic pain and insomnia. Patient-reported outcomes may improve by up to 20% with either surgery or physical therapy but are not likely to return to those seen in patients without hip pain. Although most patients return to sport after hip arthroscopy, the ability to participate at a preinjury level is seen in fewer than a quarter of patients. Return-to-sport rates with physiotherapist-led nonoperative treatment are not known.

Running Dose and Risk of Developing Lower-Extremity Osteoarthritis

Whether or not running leads to the development of knee and hip osteoarthritis has been a much-debated topic and is often a question patients pose to their physicians. Recent literature adds to a growing body of evidence suggesting that lower-dose running may be protective against the development of osteoarthritis, whereas higher-dose running may increase one's risk of developing lower-extremity osteoarthritis. However, running dose remains challenging to define, leading to difficulty in providing firm recommendations to patients regarding the degree of running which may be safe. Furthermore, when counseling patients regarding their risk of developing lower-extremity osteoarthritis secondary to running, clinicians must consider many additional factors, such as the numerous health benefits from running and individual risk factors for developing osteoarthritis.

Hip-related groin pain, patient characteristics and patient-reported outcomes in patients referred to tertiary care due to longstanding hip and groin pain: a cross-sectional study

BACKGROUND

Due to advances in hip arthroscopy, the number of surgical procedures has increased dramatically. The diagnostic challenge in patients with longstanding hip and groin pain, as well as the increasing number of hip arthroscopies, may lead to a higher number of patients referred to tertiary care for consideration for surgery. Therefore, the aims were: 1) to describe the prevalence of hip-related groin pain in patients referred to tertiary care due to longstanding hip and groin pain; and 2) to compare patient characteristics and patient-reported outcomes for patients categorized as having hip-related groin pain and those with non-hip-related groin pain.

METHODS

Eighty-one patients referred to the Department of Orthopedics at Skåne University Hospital for longstanding hip and groin pain were consecutively included and categorized into hip-related groin pain or non-hip-related groin pain using diagnostic criteria based on current best evidence (clinical examination, radiological examination and intra-articular block injection). Patient characteristics (gender (%), age (years), BMI (kg/m²)), results from the Hip Sports Activity Scale (HSAS), the SF-36, the Copenhagen Hip and Groin Outcome Score (HAGOS), and pain distribution (pain manikin) were collected. Parametric and non-parametric statistics were used as appropriate for between-group analysis.

RESULTS

Thirty-three (47%) patients, (30% women, 70% men, p < 0.01), were categorized as having hip-related groin pain. The hip-related groin pain group had a higher activity level during adolescence (p = 0.013), and a higher pre-injury activity level (p = 0.034), compared to the non-hip-related groin pain group. No differences (mean difference (95% CI)) between hip-related groin pain and non-hip-related groin pain were observed for age (0 (- 4; 4)), BMI (- 1.75 (- 3.61; 0.12)), any HAGOS subscales (p ≥ 0.318), any SF-36 subscales (p ≥ 0.142) or pain distribution (p ≥ 0.201).

CONCLUSIONS

Only half of the patients referred to tertiary care for long-standing hip and groin pain, who were predominantly men with a high activity level, had hip-related groin pain. Self-reported pain localization and distribution did not differ between patients with hip-related groin pain and those with non-hip-related groin pain, and both patient groups had poor perceived general health, and hip-related symptoms and function.

Prevalence and Clinical Implications of Chondral Injuries After Hip Arthroscopic Surgery for Femoroacetabular Impingement Syndrome

BACKGROUND

Studies on the effect of partial- and full-thickness chondral damage of the hip on outcomes and the ability to achieve meaningful clinical outcomes are limited.

PURPOSE

To determine the effect of full- and partial-thickness chondral injuries on 2-year outcomes in patients undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) compared with patients without chondral damage, and to identify significant predictors of achieving the patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID).

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data from consecutive patients with evidence of chondromalacia at the time of primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS by a single fellowship-trained surgeon between January 2012 and September 2016 were reviewed. Patients were divided into groups with partial-thickness (grade I-III) or full-thickness (grade IV) chondral defects and matched by age and body mass index (BMI) to patients without chondral injuries. Preoperative and postoperative outcomes were compared among the 3 groups, and a binary logistic regression analysis was utilized to identify significant predictors of achieving the MCID and PASS.

RESULTS

There were 634 patients included in the analysis, with a mean age of 34.5 ± 10.9 years and a mean BMI of 25.2 ± 4.7 kg/m². A total of 493 (77.8%) patients had no evidence of chondral damage, 92 (14.5%) patients had partial-thickness chondral defects, and 49 (7.7%) patients had full-thickness chondral defects. There were statistically significant differences in the Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris Hip Score, pain, and satisfaction (P < .01) among the 3 groups. Patients with grade IV chondromalacia experienced the poorest outcomes and lowest percentage of achieving the PASS. Predictors for achieving any PASS threshold included preoperative alpha angle (odds ratio [OR], 0.96; P = .016), absence of preoperative limping (OR, 7.25; P = .002), absence of preoperative chronic pain (OR, 5.83; P = .019), primary hip arthroscopic surgery (OR, 0.17; P = .050), patients who self-identified as runners (OR, 2.27; P = .037), and Tönnis grade 0 (OR, 2.86; P = .032). Male sex (OR, 2.49; P = .015) was the only predictor of achieving any MCID threshold.

CONCLUSION

Patients with grade IV chondral defects experienced worse functional outcomes, lower satisfaction, and increased pain when compared with both patients without chondral damage or grade I-III chondromalacia at 2-year follow-up. Several predictors were associated with achieving clinically significant function in patients undergoing hip arthroscopic surgery for FAIS.

Demographic and Radiographic Factors Associated With Intra-articular Hip Cartilage Injury: A Cross-sectional Study of 1511 Hip Arthroscopy Procedures

BACKGROUND

Moderate to severe (grade 3-4) hip joint cartilage injury seems to impair function in patients with femoroacetabular impingement syndrome.

PURPOSE

To investigate whether demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients were identified in the Danish Hip Arthroscopy Registry. The outcome variables were acetabular cartilage injury (modified Beck grade 0-2 vs 3-4) and femoral head cartilage injury (International Cartilage Repair Society grade 0-2 vs 3-4). Logistic regressions assessed the association with the following: age (<30 vs 30-50 years); sex; sport activity level (Hip Sports Activity Scale); alpha angle (AA) assessed as normal (AA <55°), cam (55°≤ AA <78°), or severe cam (AA ≥78°); lateral center-edge angle (LCEA) assessed as normal (25°≤ LCEA ≤ 39°), pincer (LCEA >39°), or borderline dysplasia (LCEA <25°); joint space width (JSW) assessed as normal (JSW >4.0 mm), mild reduction (3.1 mm ≤ JSW ≤ 4.0 mm), or severe reduction (2.1 mm ≤ JSW ≤ 3.0 mm).

RESULTS

A total of 1511 patients were included (mean ± SD age: 34.9 ± 9.8 years). Male sex (odds ratio [OR], 4.42), higher age (OR, 1.70), increased AA (cam: OR, 2.23; severe cam: OR, 4.82), and reduced JSW (mild: OR, 2.04; severe: OR, 3.19) were associated (P < .05) with Beck grade 3-4. Higher age (OR, 1.92), increased Hip Sports Activity Scale (OR, 1.13), borderline dysplasia (OR, 3.08), and reduced JSW (mild: OR, 2.63; severe: OR, 3.04) were associated (P < .05) with International Cartilage Repair Society grade 3-4.

CONCLUSION

Several demographic and radiographic factors were associated with moderate to severe hip joint cartilage injury. Most notably, increased cam severity and borderline dysplasia substantially increased the risk of grade 3-4 acetabular and femoral head cartilage injury, respectively, indicating that specific deformity may drive specific cartilage injury patterns in the hip joint.

Acute and Subacute Changes in Hip Strength and Range of Movement After Arthroscopy to Address Chondrolabral Pathology

BACKGROUND

Hip pain is associated with reduced muscle strength, range of movement (ROM), and function. Hip arthroscopy is undertaken to address coexistent intra-articular pathologies with the aim of reducing pain and improving function.

PURPOSE

To evaluate changes in strength and ROM in a cohort with chondrolabral pathology before surgery to 3 and 6 months after hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Sixty-seven individuals with hip pain who were scheduled for hip arthroscopy were matched with 67 healthy controls. Hip strength and ROM were collected preoperatively and at 3 and 6 months postoperatively. Repeated measures analysis of variance evaluated whether strength and ROM differed between limbs and among time points. Bonferroni post hoc tests determined differences in hip strength and ROM among testing times and between the hip pain group and matched controls.

RESULTS

Hip extension, internal rotation (IR), external rotation (ER), and adduction (P < .040) strength were greater at 3 months after surgery; all directions, including flexion, abduction, and squeeze, were greater at 6 months (P < .015). Hip flexion ROM was greater at 3 months after surgery (P = .013). Flexion, IR, and ER ROM was greater at 6 months (P < .041). At 6 months, IR ROM (P = .003) and flexion, IR, and ER strength (P < .005) remained less than matched controls.

CONCLUSION

With the exception of squeeze and flexion, all directions of hip strength and hip flexion ROM are significantly improved 3 months after arthroscopy to address chondrolabral pathology. By 6 months after arthroscopy, strength in all directions and flexion and rotation ROM are significantly improved in both limbs, but hip flexion, IR, and ER strength and IR ROM remain significantly less than that of healthy matched controls in both limbs.

Minimal Clinically Important Difference and Substantial Clinical Benefit Values for a Pain Visual Analog Scale After Hip Arthroscopy

PURPOSE

To define minimal clinically important difference (MCID) and substantial clinical benefit (SCB) values for a pain visual analog scale (VAS) in patients undergoing hip arthroscopy for femoroacetabular impingement or chondrolabral pathology.

METHODS

This was a retrospective review of prospective collected data on patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and follow-up between 335 and 395 days postsurgery, subjects completed a pain VAS and categorical self-rating of function. MCID was calculated using one-half the standard deviation (SD) of the change in 1-year pain VAS values. Receiver operator characteristic analysis was performed to determine SCB values. A change in SCB value was determined based on change in categorical self-rating of function to create "improved" and "not improved" groups. Absolute postoperative SCB scores were calculated to determine scores that would be associated with "normal" or "abnormal" function ratings.

RESULTS

Of 1,034 eligible patients, 733 (71%) met the inclusion criteria, with 537 (73%) women and 196 (27%) men having a mean age of 35.3 years (SD 13). At a mean of 352 (SD 21) days postsurgery, 536 (73%) were in the improved group and 197 (27%) in the not improved group. MCID was -15.0 mm. A change of -22.7 mm on the pain VAS was able to identify those that improved with high sensitivity (0.74) and specificity (0.63). Values of ≤10.4 mm and ≥29.0 mm were cutoffs identifying subjects that rated their function as normal or abnormal, respectively, with high sensitivity (0.79 and 0.76) and specificity (0.88 and 0.76).

CONCLUSIONS

This study provides surgeons with information to help interpret pain VAS values at a follow-up period ranging from 335 to 395 days with MCID and SCB values of -15.0 mm and -22.7 mm, respectively. Additionally, a patient who assesses a pain level at ≤10.4 mm is likely to have a normal rating of function, whereas a patient who assesses a pain level at ≥29.0 mm is likely to have an abnormal rating of function.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Hip Function 6 to 10 Months After Arthroscopic Surgery: A Cross-sectional Comparison of Subjective and Objective Hip Function, Including Performance-Based Measures, in Patients Versus Controls

Background:

Little is known about hip-related function, mobility, and performance in patients after hip arthroscopic surgery (HA) during the time that return to sports can be expected.

Purpose:

To evaluate measures of subjective and objective hip function 6 to 10 months after HA in patients compared with healthy controls and to compare objective function in the HA group between the operated and nonoperated hips.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 33 patients who had undergone HA (mean, 8.1 ± 2.6 months postoperatively) and 33 healthy participants matched on sex, age, and activity level were compared regarding subjective hip function (Copenhagen Hip and Groin Outcome Score [HAGOS]) and objective function including hip range of motion (ROM; flexion, internal rotation, and external rotation), isometric hip muscle strength (adduction, abduction, flexion, internal rotation, and external rotation), and performance-based measures: the Y Balance Test (YBT), medial and lateral triple-hop test, and Illinois agility test. Group differences were analyzed using independent-samples t tests. Paired-samples t tests were used for a comparison of the operated and nonoperated hips. Standard effect sizes (Cohen d) were provided for all outcomes.

Results:

The HA group reported worse subjective hip function than the control group (HAGOS subscores: d = –0.7 to –2.1; P ≤ .004). Objective measures of hip ROM (d = –0.5 to –1.1; P ≤ .048), hip flexion strength (d = –0.5; P = .043), and posteromedial reach of the YBT (d = –0.5; P = .043) were also reduced in the HA group, although there were no significant differences between groups regarding the remaining objective measures (d = –0.1 to –0.4; P ≥ .102 to .534). The only significant difference between the operated and nonoperated hips in the HA group was reduced passive hip flexion (d = –0.4; P = .045).

Conclusion:

Patients who had undergone HA demonstrated reduced subjective hip function compared with controls 6 to 10 months after surgery, when return to sports can be expected. While most objective strength and performance test results were comparable between the HA and control groups at 6 to 10 months after surgery, the HA group presented with impairments related to hip mobility and hip flexion strength. No consistent pattern of impairments was found in operated hips compared with nonoperated hips.

Is Microfracture Necessary? Acetabular Chondrolabral Debridement/Abrasion Demonstrates Similar Outcomes and Survival to Microfracture in Hip Arthroscopy: A Multicenter Analysis

BACKGROUND

Hip arthroscopy is becoming more advanced and commonly performed. However, significant controversy exists regarding whether high-grade acetabular cartilage lesions should be treated with debridement/abrasion or microfracture. In addition, patients treated with microfracture are subject to extended protected weightbearing rehabilitation to mitigate risk of subchondral plate fracture and to protect fibrocartilage tissue formation.

PURPOSE

To determine the midterm patient-reported outcomes and failure rate of patients with grade 3 and 4 acetabular labrum articular disruption (ALAD) lesions managed with debridement/abrasion or microfracture.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Primary arthroscopic labral repair cases at 2 centers from November 2008 to April 2016 were reviewed for patients aged <55 years with unipolar ALAD grade 3 and 4 chondrolabral acetabular delamination. Patients undergoing microfracture and debridement/abrasion were compared using the visual analog pain scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score-Sports-Specific Subscale (HOS-SSS) to determine predictors of outcomes and failure.

RESULTS

A total of 113 hips in 110 patients (66 males, 44 females; mean age, 34.5 ± 1.1 years) undergoing debridement/abrasion (n = 82) or microfracture (n = 31) were followed for a mean of 4.9 years (range, 2.0-8.5 years). Lesion size was not statistically different between the debridement/abrasion (1.3 ± 1.0 cm²) and microfracture cohorts (1.4 ± 1.0 cm²) ( P = .47). Patients undergoing debridement/abrasion achieved 3.6-point mean improvements in VAS ( P < .01), 21.2-point improvements in mHHS ( P < .01), and 25.4-point improvements in HOS-SSS ( P < .01), which were not significantly different from those observed in microfracture patients ( P≥ .20). The 5-year rate of survival free of revision surgery was 84.0% in the debridement/abrasion group and 85.6% in the microfracture group ( P = .78). The cartilage treatment technique was found not to be predictive of revision risk during both univariate (hazard ratio [HR], 1.01; P = .98) and multivariate (HR, 0.93; P = .90) analysis accounting for patient age, lesion grade, and acetabular coverage.

CONCLUSION

Patients undergoing debridement/abrasion of high-grade unipolar acetabular cartilage lesions demonstrate similar outcome scores and revision rates compared with those of patients undergoing microfracture. These outcomes support the consideration of preferential debridement/abrasion at the discretion of the treating surgeon to optimize recovery while maintaining established positive outcomes after hip arthroscopy.

Health-Related Quality of Life After Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review and Meta-analysis

CONTEXT

Hip pain from femoroacetabular impingement (FAI) can impair health-related quality of life (HRQL) but can be treated via hip arthroscopy techniques.

OBJECTIVE

To systematically assess the HRQL outcomes after arthroscopic management of FAI.

DATE SOURCES

Three online databases (EMBASE, PubMed, and Ovid [MEDLINE]) were searched for relevant literature from database inception until June 2018 and screened by 2 reviewers independently and in duplicate.

STUDY SELECTION

Level I to IV English studies that investigated HRQL outcomes after hip arthroscopy were included. Data for generic and hip-specific HRQL outcomes were collected. Mean differences were plotted in a forest plot when possible.

STUDY DESIGN

Systematic review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

A total of 29 studies were included for assessment. Of the 6476 patients (6959 hips), the mean age was 32 years (range 9-79 years) and 50.7% were female. Significant improvements were reported in all studies assessing generic HRQL outcomes, including the 12-Item Short Form Health Survey (range of mean postoperative scores, 82.2-89.8), and EuroQOL-5D scores (range of mean postoperative scores, 0.74-0.87) between 12 and 24 months postoperatively. Significant improvements were similarly identified in the hip-specific HRQL outcomes scores, with the majority of studies also reporting improvement between 12 and 24 months postoperatively. Mean improvement in International Hip Outcome Tool-33 scores from preoperative values to postoperative values ranged from 22.7 to 43.2 ( I2 = 44%), for studies with follow-up between 12 and 24 months.

CONCLUSION

Hip arthroscopy can lead to significant improvement in generic and hip-specific HRQL outcomes at 12 to 24 months postoperatively in patients with FAI who do not have advanced hip osteoarthritis. Confirmatory, high-quality, prospective studies are warranted to compare this observed improvement with other treatment modalities for FAI and to determine long-term outcomes.

Chondral lesions in the hip: a review of relevant anatomy, imaging and treatment modalities

The diagnosis and treatment of chondral lesions in the hip is an ongoing challenge in orthopedics. Chondral lesions are common and several classification systems exist to classify them based on severity, location, radiographic parameters, and potential treatment options. When working up a patient with a potential hip chondral lesion, a complete history, thorough physical exam, and ancillary imaging are necessary. The physical exam is performed with the patient in standing, supine, prone, and lateral positions. Plain film radiographs are indicated as the first line of imaging; however, magnetic resonance arthrogram is currently the gold standard modality for the diagnosis of chondral lesions outside of diagnostic arthroscopy. Multiple treatment modalities to address chondral lesions in the hip exist and new treatment modalities continue to be developed. Currently, chondroplasty, microfracture, cartilage transplants (osteochondral autograft transfer, mosaicplasty, Osteochondral allograft transplantation) and incorporation of orthobiologics (Autologous chondrocyte implantation, Autologous matrix-induced chondrogenesis, Mononuclear concentrate in platelet-rich plasma) are some techniques that have been successfully applied to address chondral pathology in the hip. Further refinement of these modalities and research in novel techniques continues to advance a surgeon’s ability to address chondral lesions in the hip joint.

Strength and range of movement deficits are associated with symptom severity in people scheduled for hip arthroscopy

BACKGROUND

Identifying the physical impairments associated with worse symptoms and greater functional limitations in people with hip pain could enable targeted rehabilitation programmes designed to improve quality of life. The objective of this study was to compare physical characteristics between subgroups of symptoms and functional limitation severity in individuals with hip pain scheduled for arthroscopic surgery.

METHODS

Hip range of motion (ROM) and muscle strength were measured in 114 individuals (48 women; aged 32 ± 8 years) with hip pain scheduled for hip arthroscopy. Pain and disability were measured with the International Hip Outcome Tool (iHOT33) subscale of Symptoms and Functional Limitation, and a cluster analysis was used to identify mild, moderate and severe subgroups. Between-group differences were then evaluated using multivariate analysis of covariance, including sex as a covariate, followed by post hoc testing. Significance was set at 0.05.

RESULTS

Lesser hip muscle strength in all directions was reported in the severe symptoms and functional limitation group compared to the mild group. Hip flexion ROM differed when comparing the moderate to both the mild and severe subgroups. Hip internal rotation did not differ between subgroups of severity.

CONCLUSIONS

Individuals with hip pain and severe scores in the iHOT33 subscale of symptoms and functional limitations present with significantly lesser hip muscle strength and hip flexion ROM than individuals with moderate or mild scores. Targeted programmes to improve hip strength and flexion ROM in more severe patients may help reduce symptoms and improve function.

SIGNIFICANCE

Individuals with severe hip pain and functional limitation possess significantly lesser muscle strength and flexion ROM than individuals with moderate or mild scores.

Do Femoral Head Osteochondral Lesions Predict a Poor Outcome in Hip Arthroscopy Patients? A Matched Control Study With Minimum 5-Year Follow-Up

PURPOSE

To determine whether the presence of femoral head (FH) lesions affects patient-reported outcomes (PROs) of patients undergoing hip arthroscopy for labral tears.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy for labral tears at our institution from April 2008 to March 2011. Patients with FH lesions were matched to those without (control) for age, body mass index, sex, and lateral center-edge angle. The inclusion criteria were FH lesions, labral tears, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery, prior hip conditions, inflammatory arthritis, Workers' Compensation claims, and Tönnis grade greater than 1. PRO scores, including the modified Harris Hip Score, Non-Arthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, were collected preoperatively and postoperatively. Visual analog scale (VAS) scores for pain and patient satisfaction were recorded.

RESULTS

We matched 96 hips with FH lesions to 96 control hips. The FH group had slightly longer follow-up (71.4 months vs 67 months, P = .004). Patients with FH lesions tended to have higher-grade acetabular lesions (grade 4 acetabular labrum articular disruption and Outerbridge grade 4 acetabular lesions). All PRO scores, VAS scores, and patient satisfaction ratings were statistically improved at latest follow-up in both groups. No statistical difference in improvement (ΔPRO and ΔVAS scores) was noted between groups. However, patients with FH lesions had a higher rate of conversion to arthroplasty (32% vs 16%, P = .0027). Patients in the control group underwent more secondary arthroscopies (14% vs 5%, P = .05).

CONCLUSIONS

Finding an FH chondral lesion at arthroscopy does not necessarily portend a worse clinical outcome or conversion to total hip arthroplasty, when controlling for other variables. Patients with FH lesions were, however, found to have worse intra-articular hip pathology. When combined with these factors, patients with FH lesions had lower outcome scores and double the rate of conversion to arthroplasty than patients without them.

LEVEL OF EVIDENCE

Level III, case-control study.

Clinical features of people with hip-related pain, but no clinical signs of femoroacetabular impingement syndrome

OBJECTIVES

Identifying impairments in hip range of motion (ROM) and muscle strength in people with hip-related pain, without signs of femoro-acetabular impingement syndrome (FAIS).

STUDY AIMS

to determine if hip strength and ROM i) differs between the symptomatic and less-symptomatic hip of people with hip-related pain; and between people with hip-related pain and healthy controls; and ii) are associated with hip-related Quality of Life and pain.

DESIGN

Cross-sectional study.

SETTING

University laboratory.

PARTICIPANTS

Thirty participants with hip-related pain who were awaiting hip arthroscopy (22 women; age = 37 ± 10yrs), 32 healthy controls (19 women; age = 30 ± 10yrs).

MAIN OUTCOME MEASURES

Hip ROM, muscle strength, pain intensity and the Hip disability and Osteoarthritis Outcome Score (HOOS) were assessed.

RESULTS

Less hip flexion ROM (p = 0.004), and extension (p = 0.004), abduction (p = 0.001) and internal rotation (IR) (p = 0.048) strength were measured on the symptomatic compared to non-symptomatic side. Hip-related pain participants had lower hip abduction strength (p = 0.045), and less flexion (p < 0.001), IR (p = 0.027) and external rotation (ER) (p = 0.019) ROM compared to controls. Less ER ROM (p = 0.03-0.04), and greater abduction (p = 0.03-0.04) and adduction strength (p = 0.02) were associated with better patient reported outcome measures.

CONCLUSIONS

Specific impairments in hip ROM and strength were identified in people with hip-related pain but no FAIS.

Identification of a Patient Acceptable Symptomatic State Score for the International Hip Outcome Tool in People Undergoing Hip Arthroscopy

PURPOSE

To determine a Patient Acceptable Symptomatic State (PASS) score for the 33-item International Hip Outcome Tool (iHOT-33) in people undergoing hip arthroscopy for primary diagnoses of femoroacetabular impingement syndrome, acetabular labral tears, and/or ligamentum teres pathology.

METHODS

Consecutive participants underwent hip arthroscopy by a single surgeon between August 2011 and May 2016. Participants were included if they were between ages 18 and 60 years and underwent hip arthroscopy for femoroacetabular impingement syndrome, acetabular labral tears, or ligamentum teres pathology. Participants were excluded if they did not speak sufficient English to complete the iHOT-33, had evidence of hip dysplasia, had less than 2 mm of joint space on anteroposterior radiograph, or underwent subsequent total hip replacement surgery. Participants completed the iHOT-33 preoperatively and at a minimum of 1 to a maximum of 5 years postoperatively. Participants were also asked to answer yes or no to the external anchor question of "Taking into account all the activities you do during your daily life, your level of pain and also your functional impairment, are you satisfied with your current state following your surgery?" A receiver operating characteristic (ROC) curve was used to identify the PASS score. Multiple logistic regression was performed to determine if patient factors, primary preoperative diagnosis, or intraoperative findings predicted achievement of the PASS score.

RESULTS

A total of 117 participants undergoing hip arthroscopy were included: 72 women (61.1%) and 45 men (38.5%) with mean age of 36.81 years (18-59). Forty-two (35.9%) had cam morphology, 18 (15.4%) had pincer morphology, 78 (67.2%) had labral tears, and 97 (82.9%) had ligamentum teres tears. Mean time to final follow-up was 2.25 years (range, 1-5). The PASS score at a mean of 2.25 years postoperatively was 58 as determined by the cutoff threshold on the ROC curve with the lowest difference between sensitivity and specificity (area under the ROC curve 0.88; P < .01; 95% confidence interval [CI], 0.81-0.95). No factors were predictors of achievement of the PASS score in this study (P > .05), including age (odds ratio [OR], 0.71; 95% CI, 0.32-1.56), sex (OR, 1.02; 95%, CI 0.98-1.06), preoperative iHOT-33 score (OR, 1.002; 95% CI, 0.98-1.03), primary preoperative diagnosis (OR, 0.86; 95% CI, 0.53-1.40), cam morphology (OR, 1.19; 95% CI, 0.54-2.64), Pincer morphology (OR, 0.50; 95%, CI 0.18-1.38), acetabular labral tears (OR, 1.93; 95% CI, 0.88-4.26), Outerbridge grade 3-4 chondral damage (OR, 0.97; 95% CI, 0.42-2.25), and ligamentum teres pathology (OR, 0.95; 95% CI, 0.35-2.61).

CONCLUSIONS

This study reports a PASS score of 58 for the iHOT-33 at 2 years following hip arthroscopy. The PASS score will assist in assessing response to hip arthroscopy in research and clinical settings.

LEVEL OF EVIDENCE

Level II, retrospective prognostic study.