Pain, activities of daily living and sport function at different time points after hip arthroscopy in patients with femoroacetabular impingement: a systematic review with meta-analysis

Running biomechanics in people with femoroacetabular impingement syndrome: A cross-sectional analysis of sex differences and relationships with patient reported outcome measures

OBJECTIVES

(i) Investigate if lower-limb running biomechanics differ between women and men with femoroacetabular impingement syndrome, and (ii) explore whether sex-specific relationships between lower-limb running biomechanics and symptom severity and sport-related concerns exist.

DESIGN

Cross-sectional.

SETTING

Gait laboratory.

PARTICIPANTS

Twenty women and 22 men enrolled in a clinical trial of physiotherapist-led treatments for femoroacetabular impingement syndrome.

MAIN OUTCOME MEASURES

Kinematics and kinetics of hip, knee, and ankle joints during the stance phase (calculated from three-dimensional biomechanics data) were compared using statistical parametric mapping. The International Hip Outcome Tool-33 and Copenhagen Hip and Groin Outcomes Score quantified hip-related symptom severity and sport-related concerns.

RESULTS

Women had larger hip adduction angles (34%-44% of stance,p = 0.045) than men. For kinetics, women displayed larger external hip extension moments (77%-100%,p = 0.001), smaller knee extension moments (80%-100%,p = 0.007), and smaller ankle dorsiflexion moments (26%-67%,p < 0.001) than men. Worse sport-related concern was associated with a larger peak hip extension angle (0.18, 95%CI 0.05,0.31) and smaller hip flexion moment impulse (0.14∗10-2, 95% CI 0.02∗10-2,0.25∗10-2) in women, and smaller hip external rotation moment impulse in men (0.06∗10-2, 95% CI 0.01∗10-2,0.11∗10-2).

CONCLUSIONS

Women and men with FAI syndrome display differences in lower-limb running biomechanics and relationships between symptom severity and running biomechanics are sex-dependent, warranting consideration in future analyses.

Strength, mobility, and functional outcomes 2.5 months after hip arthroscopy for femoroacetabular impingement syndrome: A Cross-sectional Study

OBJECTIVE

Short-term deficits after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remain poorly understood. We assessed muscle strength, hip range of motion, and functional task performance 2.5 months after surgery and analyzed their association with self-reported function.

DESIGN

Cross sectional study.

PARTICIPANTS

52 patients.

MAIN OUTCOME MEASURES

Maximal isometric strength (hip flexion with both straight and flexed hip/knee, abduction and external rotation), hip range of motion (flexion, external and internal rotation), and functional tasks (bipodal/unipodal squat, bilateral vertical jump, single-leg distance hop). Between-limb differences were analyzed using paired t-tests, and the Limb Symmetry Index (LSI) was calculated.

RESULTS

The operated hip showed lower hip flexion strength (LSI = 88.4%; ES = -0.549; p < 0.001) and reduced range of motion (LSI = 75.4-92.4%; ES = -0.479 to -1.02; all p < 0.01) compared to the non-operated hip. Functional task performance did not differ between operated and non-operated hips (all p > 0.05).

CONCLUSION

Patients showed alterations in hip flexion strength and range of motion post-surgery, but functional task performance was unaffected. Targeted assessment and intervention may be needed to improve outcomes after surgery for FAIS.

Outcomes of Painful Hips After Hip Arthroscopy Surgery for Femoroacetabular Impingement

The benefits of hip arthroscopic surgery for femoroacetabular impingement are well-established. Hip arthroscopic surgery rates have risen dramatically over the last decade. Some patients, however, may continue to experience hip symptoms after surgery and are dissatisfied with their inability to return to desired optimal activity levels. The purpose of the study is to understand the long-term outcomes of patients with painful hips after hip arthroscopy for femoroacetabular impingement. This is a retrospective study of the outcomes of painful hips after hip arthroscopy for femoroacetabular impingement, with four to 14-year follow-up from 2008 to 2022. A total of 84 hip arthroscopies were performed. Most of the patients had labral tear debridement and shaving of the aspherical femoral head also known as cam lesion, and five patients had repair for labral tear. There were eight patients who had bilateral hip involvement. There were 27 men and 57 females between the second to fifth decades. The electronic patient's records and radiological images were reviewed, and patient outcomes were graded as pain-free hip (asymptomatic) or painful hip (persistent pain and symptoms of instability). After hip arthroscopy surgery, 55% (46) of hips were graded pain-free in patients who were mostly in their 20s and 30s, while 45% (38) of hips had persistent pain. These patients were in their third or fifth decade. In the painful hip cohort, 33 patients had one hip arthroscopic surgery, while five patients had multiple repeat hip arthroscopies in the same hip over a three to six-year period. Bilateral hip arthroscopies were performed at different times in eight patients of which five individuals experienced painful hip outcomes. There were seven females and one male in their 30s and 40s. The labral tear was repaired in five patients, and two patients had painful hip outcomes. Both were females in their 20s and 30s. Patients with chronic painful hips after hip arthroscopic surgery were investigated to identify the cause of the pain. If no cause was established, then they were finally referred to pain specialist clinicians for pain management. This cohort had seven patients between 28 and 43 years. Six were female and one was male. Total hip replacement (THR) was performed in four patients (4.7%). Conversely, 95.3% of patients did not need THR during the study period of 14 years. Hip arthroscopy can be an effective treatment for femoroacetabular impingement. Careful patient selection and a holistic approach are vital for a good patient outcome. The success rate of the pain-free hip after hip arthroscopy decreases with increasing age of the patient, particularly in the female gender. Patients with grade II and more degenerative chondral changes do not perform well. Patients in their fourth and fifth decade can benefit from hip arthroscopy provided a comprehensive discussion of the expected outcomes is conducted prior to surgery. Overall, hip arthroscopy remains a valuable tool, but it is important to be conscious of its limitations and potential challenges.

Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models

OBJECTIVE

Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state.

METHODS

Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019).

RESULTS

The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination.

CONCLUSION

Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery

BACKGROUND

Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI).

PURPOSE

To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed.

RESULTS

Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up.

CONCLUSION

Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

In search of excellence

A little while ago, I had the opportunity to spend some time in the operating room (theatre) of one of the world's most experienced and technically skilful hip arthroscopists. How I wish I had made the effort to visit this surgeon earlier in my career and how I regret that there are still so many surgeons I have failed to visit. Every surgeon who has allowed me into their operating room has shown me something that has enhanced my practice and learning to execute their manoeuvres always adds to the pleasure of surgical practice.

Hip Labral Morphological Changes in Patients with Femoroacetabular Impingement Speed Up the Onset of Early Osteoarthritis

Over the last decade, evidence has mounted for a prominent etiologic role of femoroacetabular impingement (FAI) in the development of early hip osteoarthritis (OA). The aim of this study was to compare the ultrastructure and tissue composition of the hip labrum in healthy and pathological conditions, as FAI and OA, to provide understanding of structural changes which might be helpful in the future to design targeted therapies and improve treatment indications. We analyzed labral tissue samples from five healthy multi-organ donors (MCDs) (median age, 38 years), five FAI patients (median age, 37 years) and five late-stage OA patients undergoing total hip replacement (median age, 56 years). We evaluated morpho-functional by histology and transmission electron microscopy. Extracellular matrix (ECM) structure changes were similar in specimens from FAI compared to those from patients with OA (more severe in the latter) showing disorganization of collagen fibers and increased proteoglycan content. In FAI and in OA nuclei the chromatin was condensed, organelle degenerated and cytoplasm vacuolized. Areas of calcification were mainly observed in FAI and OA labrum, as well as apoptotic-like features. We showed that labral tissue of patients with FAI had similar pathological alterations of tissue obtained from OA patients, suggesting that FAI patients might have high susceptibility to develop OA.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome Shows Good Outcomes and Low Revision Rates, With Young Age and Low Postoperative Pain Score Predicting Excellent 5-Year Outcomes

PURPOSE

To evaluate the clinical outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and their predictors at a minimum 5 years' follow-up.

METHODS

We retrospectively analyzed patients with FAIS after first-time unilateral hip arthroscopy between January 2010 and July 2016. Patient-reported outcomes (PROs) included the validated modified Harries Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). We included patients with Tönnis grade 0 or 1 and reported PROs, and excluded patients with previous hip diseases or bilateral symptoms. Bivariate and multivariate analyses were used for data analysis.

RESULTS

We included 159 patients with a mean follow-up of 6.4 years, aged 36.18 ± 8.61 years, 41.5% female, and a mean body mass index of 23.61 ± 3.45. The mean postoperative mHHS was 88.82 ± 11.60, and the mean Pain VAS was 1.93 ± 1.89, significantly better than before surgery (P < .001). Postoperative alpha angle (P = .003) and lateral center edge angle (P < .001) were significantly decreased. Most patients (83.7%) achieved clinically important improvement based on patient-acceptable symptom state and minimal clinically important difference (MCID). The overall revision surgery rate was 2.5%. There were no conversions to total hip arthroplasty. Bivariate analysis indicated that age (P < .001), preoperative mHHS (P = .002), and postoperative Pain VAS (P <.001) correlated with postoperative mHHS at a minimum 5 years' follow-up. Multivariate regression analysis of MCID showed that age (P <.001), preoperative PROs (P < .01 for both), and postoperative Pain VAS (P < .001) were significant outcome predictors.

CONCLUSION

Patients with FAIS after first-time unilateral hip arthroscopy showed significant improvement in PROs at mid-term follow-up, with a low revision surgery rate. Young patients and those with low postoperative Pain VAS showed excellent outcomes at a minimum 5 years' follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Are Exercise Therapy Protocols For The Treatment of Hip-Related Pain Adequately Described? A Systematic Review of Intervention Descriptions

Background

Hip-related pain is an umbrella term encompassing pain from non-arthritic hip joint pathologies, such as femoroacetabular impingement syndrome, hip dysplasia, and labral tears. Exercise therapy is commonly recommended for these conditions, but the reporting completeness of these interventions is currently unclear.

Purpose

The aim of this systematic review was to assess the reporting completeness of exercise therapy protocols for people with hip-related pain.

Study design

Systematic review according to PRISMA guidelines.

Materials and Methods

A systematic search was conducted, searching the MEDLINE, CINAHL, and Cochrane databases. The search results were independently screened by two researchers. Inclusion criteria were studies using exercise therapy in people with non-arthritic hip-related pain. Two independent researchers used the Cochrane risk of bias tool version 2 to analyze risk of bias, and the Consensus on Exercise Reporting Template (CERT) checklist and score (1-19) to synthesize reporting completeness.

Results

Fifty-two studies used exercise therapy for hip-related pain, but only 23 were included in the synthesis as 29 studies had no description of the intervention. CERT scores ranged from 1 to 17 (median 12, IQR 5-15). The most well-described items were tailoring (87%), and the least well-described items were motivation strategies (9%) and starting level (13%). Studies used exercise therapy alone (n=13), or in combination with hip arthroscopy (n=10).

Conclusion

Only 23 of 52 eligible studies reported sufficient details to be included in the CERT synthesis. The median CERT score was 12 (IQR 5-15), with no study reaching the maximum score of 19. Lack of reporting makes it difficult to replicate interventions in future research, and to draw conclusions on efficacy and dose-response to exercise therapy for hip-related pain.

Level of evidence

Level 1, systematic review.

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.

Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy

BACKGROUND

Previous studies have demonstrated a clinically impactful change in patients between 1 and 2 years after hip arthroscopy. Assessment of differences in patient-specific factors between patients who remain the same and those who change (ie, either improve or decline) could provide valuable outcome information for orthopaedic surgeons treating those patients.

PURPOSE

To identify patients who experienced change in functional status between 1 and 2 years after hip arthroscopy for femoroacetabular impingement syndrome and assess differences in patient-specific factors between those who improved, remained the same, or declined in functional status.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data for patients who underwent hip arthroscopy at 1 of 7 centers were analyzed retrospectively at 1 year and 2 years postoperatively. Patients were categorized as "improved,""remained the same," or "declined" between 1- and 2-year follow-up based on the 12-item International Hip Outcome Tool (iHOT-12) minimal clinically important difference (MCID) value. A 1-way analysis of variance was used to assess differences in iHOT-12 scores, age, body mass index (BMI), alpha angle, and center-edge angle (CEA) between groups. Chi-square analyses were used to assess differences in the proportions of male and female patients in the outcome groups.

RESULTS

The study included 753 patients (515 women and 238 men), whose mean ± SD age was 34.7 ± 12 years. Average 1-year (±1 month) and 2-year (±2 months) iHOT-12 scores for all patients were 73.7 and 74.9, respectively. Based on the calculated MCID of ±11.5 points, 162 (21.5%) patients improved, 451 (59.9%) remained the same, and 140 (18.6%) declined in status between 1- and 2-year follow-up. Those who improved between 1 and 2 years had lower 1-year iHOT-12 scores (P < .0005). We found no difference in age, BMI, alpha angle, CEA, or sex between groups (P > .05).

CONCLUSION

Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. Those with iHOT-12 scores indicating abnormal function at 1 year improved beyond the MCID at 2 years follow-up. Thus, any decisions about the failure or success of arthroscopic hip procedures should not be made until at least the 2-year follow-up. Failing to thrive at 1-year follow-up may not accurately predict outcomes at year 2 or beyond. This could potentially decrease the perceived need for revision surgery in patients who do not thrive before 2-year follow-up.

Hip kinematics and kinetics in patients with femoroacetabular impingement syndrome before and 1 year after hip arthroscopic surgery. Results from the HAFAI cohort

INTRODUCTION

Patients with femoroacetabular impingement syndrome (FAIS) experience decreased function. Consequently, earlier studies have evaluated gait biomechanics in these patients, but a larger study evaluating gait biomechanics before and after an intervention standardising gait speed is lacking. We aimed at investigating gait kinematics and kinetics in patients with FAIS compared with pain-free controls before and 1 year after hip arthroscopic surgery. Secondary, we aimed at analysing gait pattern separately for the sexes and to investigate associations between peak kinematics and kinetics and the Copenhagen Hip and Groin Outcome Score (HAGOS).

MATERIALS AND METHODS

Sixty patients with FAIS and 30 pain-free controls were tested at a standardised gait speed (1.40 m/s ± 10%). Patients were tested twice: before and 1 year after surgery. Kinematics and kinetics were recorded using infrared high-speed cameras and a force plate. Participants answered HAGOS.

RESULTS

The largest difference among groups was that gait differed between males and females. Neither before nor after surgery could we demonstrate large alterations in gait pattern between patients and pain-free controls. Male patients demonstrated associations between peak kinematics and kinetics and HAGOS Sports function.

CONCLUSIONS

Gait pattern was only vaguely altered in patients with FAIS compared with pain-free controls before and after surgery when using at standardised gait speed. Hence, analysing gait in patients with FAIS does not seem of major importance. Nevertheless, there was an association between HAGOS Sports function and peak kinematics and kinetics in male patients, implying that there could be a clinical importance.

Do the outcomes of hip arthroscopy for femoroacetabular impingement change over time?

BACKGROUND

The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up.

HYPOTHESIS

We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up.

PATIENTS AND METHODS

Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis.

RESULTS

Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25-37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75-91.25) and 85.8 (IQR 66.7-96.7) respectively (p<0.001). Medium-term survivorship was 91.2%. Survivorship following labral repair was 94.2%, and 81.3% following labral debridement (p=0.09).

DISCUSSION

Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up.

LEVEL OF EVIDENCE

IV, Case series.

Five-Year Follow-up After Hip Arthroscopic Surgery in the Horsens-Aarhus Femoroacetabular Impingement (HAFAI) Cohort

Background:

Patients with femoroacetabular impingement syndrome (FAIS) are offered hip arthroscopic surgery to decrease hip pain, improve their function, and decrease development of hip osteoarthritis (OA). Nonetheless, long-term follow-up data are few.

Purpose:

To investigate patient-reported outcomes, clinical tests, reoperations, and radiographic status 5 years after primary hip arthroscopy in patients with FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 60 patients (age, 36 ± 9 years; 63% female) diagnosed with FAIS were included in the study and followed for 5 years after hip arthroscopy. Follow-up included Copenhagen Hip and Groin Outcome Score (HAGOS); Hip Sports Activity Scale; and clinical tests (flexion, adduction, internal rotation [FADIR]; flexion, abduction, external rotation [FABER]; and psoas muscle/tendon major pain provocation). Radiographic evaluation included lateral joint-space width (LJSW) and Tönnis classification for hip OA. Reoperations and conversion to total hip replacement (THR) were recorded. We calculated the proportion of patients who exceeded the minimal important change (MIC), achieved the Patient Acceptable Symptom State (PASS), and were within the 95% reference interval of age- and sex-matched persons with no hip problems. Changes were investigated using paired t tests.

Results:

Compared with preoperatively, all HAGOS subscales were improved substantially 5 years after surgery (mean, ≥21 points; P < .001), and 67% to 89% of patients reported improvements exceeding MIC. Between 56% and 80% achieved PASS, but only 7% to 24% reached the 95% reference interval for the HAGOS subscales. A total of 36% had a positive FADIR test and 25% had a positive FABER test, which were improvements compared with preoperatively (P < .001 for both). Patients with a positive FADIR test had significantly worse HAGOS subscales. Six patients (10%) had a THR since their primary hip arthroscopy. In the remaining patients, the mean LJSW was decreased (-0.4 mm; P = .043), and hip OA had worsened in 9 patients (23%; P = .003).

Conclusion:

Five years after surgery, the majority of patients experienced HAGOS improvements exceeding MIC while also showing an acceptable PASS. However, clinical tests, participation in physical activities, and quality of life indicated that many patients still experience hip problems.

Registration:

NCT04590924 (ClinicalTrials.gov identifier).

A comparison of 6-month outcomes between periacetabular osteotomy with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement

PURPOSE

To compare early outcomes of periacetabular osteotomy (PAO) with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement (FAI) and chondrolabral pathology using patient-reported outcomes measurement information system (PROMIS).

MATERIALS AND METHODS

Consecutive patients scheduled for PAO with concomitant hip arthroscopy (PAO + HA) or isolated hip arthroscopy (HA) between the ages of 15 and 30 years old were prospectively included in the study. Based on power analysis, subjects were recruited until there were 22 subjects in the PAO + HA group. These subjects were then gender matched to the HA group. The PROMIS, with six subscales and two global health measures, were completed during preoperative and 6-month follow-up visits. One-way ANOVA was performed to compare intake information of age, symptom duration, body mass index, and Beighton scores as well as preoperative and 6-month postoperative PROMIS scores between the PAO + HA and HA.

RESULTS

22 consecutive subjects undergoing PAO + HA were all females (average age 20.0 years) and matched to 22 consecutive females (average age 22.6) in the HA group. ANOVA did not find a significant difference between the two groups when comparing intact information, with exception of age (p = 0.04). A significant difference was also not identified (p ≥ 0.05) between the two groups on preoperative or 6-month postoperative PROMIS scores. The largest difference in 6-month postoperative scores between the two groups was 4.4 points on physical function subscale.

CONCLUSION

Outcomes at 6 months were not significantly different when comparing PAO + HA to HA for FAI and chondrolabral pathology in females under 30 years of age. The more extensive surgery with a prolonged protective period associated with PAO do not seem to negatively impact outcomes at 6 months when compared to HA. These finding support the use of PAO + HA, particularly if the patient and/or surgeon were concerned about prolonged disability, metal health issues, and/or higher pain levels that might be associated with the PAO procedure.

Osteochondral Lesions of the Ankle Treated with Bone Marrow Concentrate with Hyaluronan and Fibrin: A Single-Centre Study

Osteochondral defects of the ankle (OCD) are being increasingly identified as a clinically significant consequence of injury to the ankle, with the potential to lead to osteoarthritis if left untreated. The aim of this retrospective cohort study was to evaluate a single-stage treatment of OCD, based on bone marrow aspirate (BMA) centrifuged to produce bone marrow concentrate (BMC). In a dual syringe, the concentrate was mixed with thrombin in one syringe, whereas hyaluronan and fibrinogen were mixed in a second syringe. The two mixtures were then injected and combined into the prepared defect. Clinical outcome and quality of life scores (MOXFQ and EQ-5D) were collected at baseline and yearly thereafter. Multilevel models were used to analyse the pattern of scores over time. Ninety-four patients were treated between 2015 and 2020. The means of each of the three components of the MOXFQ significantly improved between baseline and 1 year (p < 0.001 for each component), with no further change from year 1 to year 3. The EQ-5D index also improved significantly from baseline to 1 year, with no evidence for further change. Our results strongly indicate that this BMC treatment is safe for, and well tolerated by, patients with OCD of the ankle as both primary treatment and those who have failed primary treatment. This technique provides a safe, efficacious alternative to currently employed cartilage repair techniques, with favourable outcomes and a low complication rate at 36 months.

Correlation between the range of rotation of the hip and the radiographic signs of cam and pincer morphology in femoroacetabular impingement syndrome

Objective

To determine whether hip rotation correlates with the radiographic signs of cam or pincer deformity after hip arthroscopy in patients with femoroacetabular impingement syndrome.

Materials and Methods

This was a single-center retrospective study of data collected between 2014 and 2017. The study sample included 65 patients between 18 and 55 years of age who underwent hip arthroscopy for the treatment of unilateral femoroacetabular impingement. The following data were collected for the periods prior to and six months after surgery range of medial and lateral rotation of the hip; measures on anteroposterior X-rays of the pelvis obtained in the standing position and on ateral X-rays in the Ducroquet profile view; and score on the 33-item International Hip Outcome Tool.

Results

Mean preoperative and postoperative values were as follows: 19.26 ± 10.39° and 30.95 ± 3.52°, respectively, for medial rotation of the hip (p < 0.001); 73.85 ± 6.62° and 68.12 ± 5.04°, respectively, for the anteroposterior alpha angle (p < 0.001); 56.97 ± 6.09° and 50.61 ± 5.39°, respectively, for the lateral alpha angle (p < 0.001); and 0.17 ± 0.11 and 0.07 ± 0.08, respectively, for the acetabular retroversion index (p < 0.001). The crossover sign was identified in 75.4% of the patients before surgery and in 44.6% after (p < 0.001). Although there was an increase in the range of hip rotation and an improvement in radiographic parameters after arthroscopy, we detected no direct correlation between the two.

Conclusion

Hip arthroscopy can improve medial rotation of the hip, as well as reducing cam and pincer deformities, in patients with femoroacetabular impingement syndrome. However, those findings do not appear to be directly correlated.

Hip joint range of motion is restricted by pain rather than mechanical impingement in individuals with femoroacetabular impingement syndrome

INTRODUCTION

Discerning whether range of motion (ROM) is restricted by morphology or other pain sources is challenging in patients with femoroacetabular impingement syndrome (FAIS). Computed tomography (CT) motion simulation provides a hypothetical ROM based on morphology. This study aimed to explore associations between ROM measured using CT motion simulation and maximum passive ROM measured clinically using three dimensional (3D) motion analysis in patients with FAIS, prior to and post arthroscopic hip surgery.

MATERIALS AND METHODS

Eight males with FAIS (in total 12 hip joints) were included in this explorative feasibility study. Participants were examined using CT according to a low-dose protocol prior to and 7-months post arthroscopic surgery. Software was used to simulate at which ROM the impingement would occur. With the hip in 90 degrees' flexion, maximum passive range of internal hip rotation, and maximum passive internal hip rotation coupled with adduction was examined clinically using 3D motion analysis pre- and postoperatively. Spearman rank correlation coefficients and linear regressions examined associations between methods.

RESULTS

Preoperatively, the correlation between maximum internal hip rotation measured using CT motion simulation and 3D motion analysis was strong (r = 0.71, p = 0.009). Linear regressions demonstrated that maximal internal rotation measured using CT motion simulation was predominantly larger than when measured using 3D motion analysis. Postoperatively, and when maximum internal rotation was coupled with adduction, no correlations were found between the two methods.

CONCLUSIONS

The hypothetical morphology restricted ROM is larger than clinically assessed pain restricted ROM, both prior to and post hip arthroscopy. These findings suggest that ROM is restricted by pain rather than mechanical, morphology-based impingement in individuals with FAIS.

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.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome Results in 2 Recovery Patterns Based on Preoperative Pain and on Arthritis: Improvers and Non-improvers

Purpose

To analyze whether subgroups of patients could be distinguished with different functional recovery trajectories after hip arthroscopy for femoroacetabular impingement (FAI) syndrome and to identify differences between those subgroups using data from our prospective cohort registration.

Methods

We retrospectively reviewed the prospectively registered data of patients who had undergone hip arthroscopy for FAI syndrome in our clinic from 2015 through 2018. Latent class growth modeling and growth mixture modeling were used to identify and classify groups of patients according to the trajectory of functional recovery using the Hip Outcome Score–Activities of Daily Life (HOS-ADL). We used univariable analysis and descriptive statistics to explore whether differences in group membership could be identified.

Results

A total of 100 patients were analyzed. Growth mixture modeling identified 2 main types of recovery pattern after surgery: patients in whom the HOS-ADL improved significantly after surgery to 90, whom we called the “improvers” (with fast initial improvement within 3 months that is maintained during follow-up), and patients who did not significantly benefit from surgery (with only mild improvement in the HOS-ADL at 3 months and no further change during follow-up), whom we called the “non-improvers.” Univariable analysis and comparison of differences between subgroups showed higher preoperative visual analog scale scores for pain and more intraoperative arthrosis of the femoral head for the non-improvers.

Conclusions

We identified 2 main types of recovery pattern after arthroscopic treatment of FAI syndrome: improvers and non-improvers. Both groups recover in a different manner postoperatively. Preoperative pain and intraoperative arthrosis of the femoral head differed in the non-improvers compared with the improvers.

Level of evidence

Level III, retrospective cohort study.

The Natural Course of Recovery After Hip Arthroscopy for Femoroacetabular Impingement According to the International Hip Outcome Tool-12 and Hip Outcome Score Sports Subscale

BACKGROUND

A paucity of literature exists regarding trajectories of functional and sports-specific recovery after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine if subgroups of patients exist based on the recovery trajectory of patient-reported outcomes (PROs) after hip arthroscopy for FAIS in the short-term period and to determine clinical predictors for these subgroups of patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A prospectively maintained repository was queried for patients who had undergone primary hip arthroscopy for the treatment of FAIS between January 2012 and May 2018. Patients who completed the preoperative, 1-year, and 2-year International Hip Outcome Tool-12 (iHOT-12) or the Hip Outcome Score Sports Subscale (HOS-SS) were included. The latent class growth analysis (LCGA) and growth mixture models (GMMs) were used to identify subgroups of patients based on trajectories of recovery for the iHOT-12 and the HOS-SS utilizing preoperative, 1-year, and 2-year follow-ups. LCGA and GMM models using 1 to 6 classes for each PRO were performed, and the best-fit model for each PRO was selected. After final model selection, a multivariable multinomial logistic regression was performed, with the largest class being the reference group to determine clinical predictors of subgroup membership.

RESULTS

A total of 443 and 556 patients were included in the iHOT-12 and HOS-SS analyses, respectively. For the iHOT-12, we identified the following 3 subgroups: early progressors (70%), late regressors (22.3%), and late progressors (7.7%). Predictors of late regression were workers' compensation status, psychiatric history, preoperative chronic pain, and lower preoperative iHOT-12 scores; and late progressors were less likely to participate in sports. For the HOS-SS, we identified the following 4 subgroups: early progressors (47.7%), late regressors (17.4%), late progressors (6.8%), and steady progressors (28.1%). Predictors of less favorable recovery trajectories (late regressors and late progessors) were older age, male sex, back pain, psychiatric history, preoperative chronic pain, greater alpha angle, and lower preoperative HOS-SS scores.

CONCLUSION

Using the growth mixture modeling, 3 natural courses of health-related quality of life (early progression, late regression, and late progression) and 4 natural courses of recovery of athletic function (steady progression, late regression, late progression, and early progression) were identified. Preoperative psychiatric conditions, chronic pain, workers' compensation status, and lower iHOT-12 scores were predictive of less than favorable trajectories of recovery according to the iHOT-12, and male sex, older age, back pain, preoperative narcotic use, and lower preoperative HOS-SS were predictors of less favorable recovery trajectories according to the HOS-SS.

Clinical validation of the Oswestry-Bristol Classification as part of a decision algorithm for trochlear dysplasia surgery

AIMS

The Oswestry-Bristol Classification (OBC) is an MRI-specific assessment tool to grade trochlear dysplasia. The aim of this study is to validate clinically the OBC by demonstrating its use in selecting treatments that are safe and effective.

METHODS

The OBC and the patellotrochlear index were used as part of the Oswestry Patellotrochlear Algorithm (OPTA) to guide the surgical treatment of patients with patellar instability. Patients were assigned to one of four treatment groups: medial patellofemoral ligament reconstruction (MPFLr); MPFLr + tibial tubercle distalization (TTD); trochleoplasty; or trochleoplasty + TTD. A prospective analysis of a longitudinal patellofemoral database was performed. Between 2012 and 2018, 202 patients (233 knees) with a mean age of 24.2 years (SD 8.1), with recurrent patellar instability were treated by two fellowship-trained consultant sports/knee surgeons at The Robert Jones and Agnes Hunt Orthopaedic Hospital. Clinical efficacy of each treatment group was assessed by Kujala, International Knee Documentation Committee (IKDC), and EuroQol five-dimension questionnaire (EQ-5D) scores at baseline, and up to 60 months postoperatively. Their safety was assessed by complication rate and requirement for further surgery. The pattern of clinical outcome over time was analyzed using mixed regression modelling.

RESULTS

In all, 135 knees (mean age 24.9 years (SD 9.4)) were treated using a MPFLr. Ten knees (7.4%) required additional surgery. A total of 50 knees (mean age 24.4 years (SD 6.3)) were treated using MPFLr + TTD. Ten (20%) required additional surgery. A total of 20 knees (mean age 19.5 years (SD 3.0)) were treated using trochleoplasty + TTD. Three patients (15%) required additional surgery. In each treatment group, there was a significant improvement in Kujala, IKDC, and EQ-5D at one year postoperatively (p < 0.001) with a recognized level of overall complication rate.

CONCLUSION

The OBC is a valid assessment tool to grade patients with trochlear dysplasia and, when used as part of the OPTA, helps to determine treatments that are safe and effective. This fulfils the requirements for its application in mainstream clinical practice. Cite this article: Bone Joint J 2021;103-B(10):1586-1594.

Preoperative Psychosocial Factors and Short-term Pain and Functional Recovery After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

CONTEXT

Low mental health scores, depression, and anxiety are associated with worse pain and functional outcomes after hip arthroscopy for patients with femoroacetabular impingement syndrome (FAIS). Preoperative screening of psychosocial factors such as self-efficacy, kinesiophobia, and pain catastrophizing may further aid in identifying patients at risk for poorer outcomes.

OBJECTIVE

To compare preoperative function and psychosocial factors between patients with and those without elevated postoperative pain 3 months after hip arthroscopy for FAIS.

DESIGN

Prospective cohort study.

SETTING

University health center.

PATIENTS OR OTHER PARTICIPANTS

Fifty-one individuals with FAIS (41 women, 10 men; age = 37.6 ± 12.3 years, body mass index = 27.1 ± 4.1 kg/m2).

MAIN OUTCOME MEASURE(S)

Preoperatively, participants completed the Pain Self-Efficacy Questionnaire (PSEQ), Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), 12-Item International Hip Outcome Tool (iHOT-12), and a 10-point visual analog scale (VAS) for hip pain at rest and during activity. Three months postoperatively, they completed the PSEQ, TSK, PCS, iHOT-12, and VAS. Preoperative scores were compared between those with (VAS ≥ 3) and those without (VAS < 3) elevated postoperative pain using Mann-Whitney U tests, and odds ratios were calculated to determine the odds of having elevated postoperative pain and lower postoperative function.

RESULTS

Participants with elevated postoperative pain at rest and during activity had worse preoperative psychosocial health (P ≤ .04). Those with elevated postoperative pain at rest had worse preoperative function (P < .001). The odds of having elevated postoperative pain at rest were 45 times and 4.5 times higher for those with low self-efficacy and high pain catastrophizing, respectively (P values ≤ .03). The odds of having elevated postoperative pain during activity were 7.1, 6.2, and 3.5 times higher for those with low self-efficacy, high kinesiophobia, and high pain catastrophizing, respectively (P values ≤ .04). The odds of having lower postoperative iHOT-12 scores were 7.5 and 14.0 times higher for those with high kinesiophobia and pain catastrophizing, respectively (P values ≤ .03).

CONCLUSIONS

Poor preoperative psychosocial health increased the odds of elevated pain and worse function 3 months after hip arthroscopy for FAIS. This is a first step in identifying the psychosocial factors that may contribute to poorer long-term hip arthroscopy outcomes.

Multi-centre randomised controlled trial comparing arthroscopic hip surgery to physiotherapist-led care for femoroacetabular impingement (FAI) syndrome on hip cartilage metabolism: the Australian FASHIoN trial

Background

Arthroscopic surgery for femoroacetabular impingement syndrome (FAI) is known to lead to self-reported symptom improvement. In the context of surgical interventions with known contextual effects and no true sham comparator trials, it is important to ascertain outcomes that are less susceptible to placebo effects. The primary aim of this trial was to determine if study participants with FAI who have hip arthroscopy demonstrate greater improvements in delayed gadolinium-enhanced magnetic resonance imaging (MRI) of cartilage (dGEMRIC) index between baseline and 12 months, compared to participants who undergo physiotherapist-led management.

Methods

Multi-centre, pragmatic, two-arm superiority randomised controlled trial comparing physiotherapist-led management to hip arthroscopy for FAI. FAI participants were recruited from participating orthopaedic surgeons clinics, and randomly allocated to receive either physiotherapist-led conservative care or surgery. The surgical intervention was arthroscopic FAI surgery. The physiotherapist-led conservative management was an individualised physiotherapy program, named Personalised Hip Therapy (PHT). The primary outcome measure was change in dGEMRIC score between baseline and 12 months. Secondary outcomes included a range of patient-reported outcomes and structural measures relevant to FAI pathoanatomy and hip osteoarthritis development. Interventions were compared by intention-to-treat analysis.

Results

Ninety-nine participants were recruited, of mean age 33 years and 58% male. Primary outcome data were available for 53 participants (27 in surgical group, 26 in PHT). The adjusted group difference in change at 12 months in dGEMRIC was -59 ms (95%CI − 137.9 to - 19.6) (p = 0.14) favouring PHT. Hip-related quality of life (iHOT-33) showed improvements in both groups with the adjusted between-group difference at 12 months showing a statistically and clinically important improvement in arthroscopy of 14 units (95% CI 5.6 to 23.9) (p = 0.003).

Conclusion

The primary outcome of dGEMRIC showed no statistically significant difference between PHT and arthroscopic hip surgery at 12 months of follow-up. Patients treated with surgery reported greater benefits in symptoms at 12 months compared to PHT, but these benefits are not explained by better hip cartilage metabolism.

Trial registration details

Australia New Zealand Clinical Trials Registry reference: ACTRN12615001177549. Trial registered 2/11/2015.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04576-z.

Subject-Specific Modeling of Femoral Torsion Influences the Prediction of Hip Loading During Gait in Asymptomatic Adults

Hip osteoarthritis may be caused by increased or abnormal intra-articular forces, which are known to be related to structural articular cartilage damage. Femoral torsional deformities have previously been correlated with hip pain and labral damage, and they may contribute to the onset of hip osteoarthritis by exacerbating the effects of existing pathoanatomies, such as cam and pincer morphologies. A comprehensive understanding of the influence of femoral morphotypes on hip joint loading requires subject-specific morphometric and biomechanical data on the movement characteristics of individuals exhibiting varying degrees of femoral torsion. The aim of this study was to evaluate hip kinematics and kinetics as well as muscle and joint loads during gait in a group of adult subjects presenting a heterogeneous range of femoral torsion by means of personalized musculoskeletal models. Thirty-seven healthy volunteers underwent a 3D gait analysis at a self-selected walking speed. Femoral torsion was evaluated with low-dosage biplanar radiography. The collected motion capture data were used as input for an inverse dynamics analysis. Personalized musculoskeletal models were created by including femoral geometries that matched each subject’s radiographically measured femoral torsion. Correlations between femoral torsion and hip kinematics and kinetics, hip contact forces (HCFs), and muscle forces were analyzed. Within the investigated cohort, higher femoral antetorsion led to significantly higher anteromedial HCFs during gait (medial during loaded stance phase and anterior during swing phase). Most of the loads during gait are transmitted through the anterior/superolateral quadrant of the acetabulum. Correlations with hip kinematics and muscle forces were also observed. Femoral antetorsion, through altered kinematic strategies and different muscle activations and forces, may therefore lead to altered joint mechanics and pose a risk for articular damage. The method proposed in this study, which accounts for both morphological and kinematic characteristics, might help in identifying in a clinical setting patients who, as a consequence of altered femoral torsional alignment, present more severe functional impairments and altered joint mechanics and are therefore at a higher risk for cartilage damage and early onset of hip osteoarthritis.

Maximal hip muscle strength and rate of torque development 6-30 months after hip arthroscopy for femoroacetabular impingement syndrome: A cross-sectional study

OBJECTIVES

Reduced sports function is often observed after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Impaired muscle strength could be reasons for this. We aimed to investigate hip muscle strength after hip arthroscopy for FAIS and its association with sports function and participation.

DESIGN

Cross-sectional study.

METHODS

We included 45 patients (34 males; mean age: 30.6 ± 5.9 years) after unilateral hip arthroscopy for FAIS (mean follow-up [range]: 19.3 [9.8-28.4] months). Maximal isometric hip muscle strength (Nm/kg) including early- (0-100 ms) and late-phase (0-200 ms) rate of torque development (Nm∗kg^-1∗s^-1) for adduction, abduction, flexion, and extension was measured with an externally fixated handheld dynamometer and compared between operated and non-operated hip. Associations between muscle strength and self-reported sports function and return to sport were investigated.

RESULTS

For maximal hip muscle strength, no between-hip differences were observed for adduction, abduction, flexion, and extension (p ≥ 0.102). For rate of torque development, significantly lower values were observed for the operated hip in flexion at both 0-100 ms (mean difference: 1.58 Nm∗kg^-1∗s^-1, 95% CI [0.39; 2.77], p = 0.01) and 0-200 ms (mean difference: 0.72 Nm∗kg^-1∗s^-1, 95% CI [0.09; 1.35], p = 0.027). Higher maximal hip extension strength was significantly associated with greater ability to participate fully in preinjury sport at preinjury level (odds ratio: 17.71 95% CI [1.77; 177.60]).

CONCLUSIONS

After hip arthroscopy for FAIS subjects show limited impairments in maximal and explosive hip muscle strength between operated and non-operated hip. Higher muscle strength was positively associated with higher sports function and ability to participate in sport.

How Many Patients Achieve an Acceptable Symptom State After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Cross-sectional Study Including PASS Cutoff Values for the HAGOS and iHOT-33

Background

Hip arthroscopy is a viable treatment for femoroacetabular impingement syndrome (FAIS). Clinically relevant improvements in hip function and pain after surgery are often reported, but it is less clear how many patients achieve an acceptable symptom state (Patient Acceptable Symptom State [PASS]).

Purpose

To investigate the proportion of patients who achieved a PASS 12 to 24 months after hip arthroscopy and to determine the cutoff scores of the 2 recommended and valid patient-reported outcome measures (the subscales of the Copenhagen Hip and Groin Outcome Score [HAGOS] and the International Hip Outcome Tool-33 [iHOT-33]) for which patients are most likely to achieve PASS.

Study Design

Cohort study; Level of evidence, 3.

Methods

Eligible study patients were identified in the Danish Hip Arthroscopy Registry. An electronic questionnaire was used to collect data on PASS, HAGOS, and iHOT-33 12 to 24 months after surgery. PASS was measured using an anchor question. Receiver operating characteristic curve analyses were applied to identify the PASS cutoff values of HAGOS and iHOT-33 scores.

Results

A total of 137 individuals (mean age at surgery, 35.4 ± 9.4 years) were included in the study at a mean follow-up of 18.5 ± 3.2 months after surgery. At follow-up, 64 individuals (46.7%; 95% CI, 38.6-55.1) reported PASS. Higher HAGOS and iHOT-33 values were observed for participants who reported PASS compared with those who did not report PASS (Cohen d ≥ 1.06; P < .001). Cutoff scores for HAGOS subscales (42.5-82.5) and iHOT-33 (67.00) showed excellent to outstanding discriminative ability in predicting PASS (area under the curve, 0.82-0.92).

Conclusion

In total, 46% of individuals having hip arthroscopy for FAIS achieved PASS at 12 to 24 months of follow-up. Patients who achieved PASS had statistically significant and substantially better self-reported hip function compared with those who did not achieve PASS. Cutoff values at HAGOS subscales and iHOT-33 showed excellent to outstanding discriminative ability in predicting patients with PASS.

Outcomes of arthroscopic femoroplasty in patients with cam lesions: Minimum 2-year follow-up

PURPOSE

Successful arthroscopic femoroplasty in patients with cam lesions have been reported in Western countries in the last two decades. However, the outcomes after arthroscopic femoroplasty in Asia have thus far only been reported in patients with borderline dysplasia and in the military population. This retrospective study was designed to evaluate the short-term clinical outcomes and radiologic outcomes after hip arthroscopy in patients with cam-type femoroacetabular impingement (FAI) at a minimum postoperative follow-up of 2 years.

METHODS

From January 2013 to December 2016, 204 hip arthroscopy procedures were performed. Of these cases, 62 patients (73 hips) underwent hip arthroscopy for cam-type FAI.

RESULTS

Of the 73 hips, 65 (89.0%) achieved gratified reduction or elimination of preoperative pain. The clinical outcomes showed improvement in scores from before surgery to the last follow-up: 67.1 ± 15.0 to 90.2 ± 6.3 for the modified Harris hip score (p < 0.001), 4.7 ± 2.5 to 7.1 ± 1.4 for the University of California Los Angeles score (p < 0.001), and 7.4 ± 1.9 to 1.8 ± 1.5 for the visual analog scale score (p < 0.001). In radiologic assessments, significant improvement was observed in the alpha angle from a mean 60.9° to 49.5° (p < 0.001) and in the head-neck offset from a mean of 3.3 mm to 6.3 mm (p < 0.001). Of the 73 hips, 65 (89.0%) achieved satisfactory reduction or elimination of preoperative pain. In subgroup analysis for the sufficiency of femoroplasty (alpha angle < 55°), the clinical outcomes were not different between the two groups.

CONCLUSION

Arthroscopic femoroplasty resulted in an 89% satisfaction at the 2-year follow-up. Therefore, hip arthroscopic femoroplasty might be an excellent alternative to open surgery and offers a greater probability of good to excellent results.

Sex Differences in Clinical Outcomes Following Surgical Treatment of Femoroacetabular Impingement

BACKGROUND

Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates.

METHODS

Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively.

RESULTS

Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes.

CONCLUSIONS

Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The forgotten joint score-12 is a valid and responsive outcome tool for measuring success following hip arthroscopy for femoroacetabular impingement syndrome

PURPOSE

The forgotten joint score-12 (FJS-12) is an outcome questionnaire designed to evaluate joint awareness. The responsiveness and validity of the English language version of the FJS-12 in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) is not known.

METHODS

Consecutive patients undergoing hip arthroscopy for a diagnosis of FAI were prospectively followed up over a 1 year period. Patients completed preoperative and postoperative FJS-12, EuroQol 5 Dimension (EQ-5D-5L), and the 12-item international hip outcome tool (iHOT-12). We evaluated construct validity with Spearman correlation coefficients for the FJS-12, and responsiveness by way of effect size and ceiling effects.

RESULTS

Forty-six patients underwent hip arthroscopy, of which 42 (91%) completed post-operative PROMs at 1 year follow-up. Construct validity was strong with the iHOT-12 (r = 0.87) and also the EQ-5D-5L (r = 0.83). The median postoperative FJS score was 50.2 (IQR 64). The mean change in score for the FJS-12 was 31 points (SD 31) (p < 0.001), with an effect size (Cohen's d) of 1.16. Preoperatively, three patients scored the lowest possible value resulting in a floor effect of 7.1%. Similarly, only three patients (7.1%) scored the best possible score post-operatively.

CONCLUSION

This is the first evaluation of the joint awareness concept in the English language version of the FJS-12 following hip arthroscopy for FAI. The FJS-12 is a valid and responsive tool for the assessment of this cohort of patients.

LEVEL OF EVIDENCE

II.

Adjunct Analgesia Reduces Pain and Opioid Consumption After Hip Arthroscopy: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Patients who undergo hip arthroscopy inevitably experience pain postoperatively; however, the efficacy and safety of adjunct analgesia to prevent or reduce pain are not well-understood.

PURPOSE

To perform a comprehensive qualitative synthesis of available randomized controlled trials evaluating the effect of adjunct analgesia on postoperative (1) pain, (2) opioid use, and (3) length of stay (LOS) in patients undergoing hip arthroscopy.

STUDY DESIGN

Systematic review.

METHODS

PubMed, OVID/MEDLINE, and Cochrane Controlled Register of Trials were queried for studies pertaining to analgesia interventions for patients undergoing hip arthroscopy. Two authors independently assessed article bias and eligibility. Data pertaining to changes in pain scores, additional analgesia requirements, length of hospital stay, and complications were extracted and qualitatively reported. Network meta-analyses were constructed to depict mean pain, opioid use, and LOS among the 3 analgesia categories (blocks, local infiltration analgesia, and celecoxib).

RESULTS

Fourteen level 1 studies were included; 12 (85.7%) reported pain reductions in the immediate and perioperative period after hip arthroscopy. Of the 7 studies that assessed an intervention (2 celecoxib, 1 fascia iliaca block, 1 lumbar plexus block, 1 femoral nerve block, 1 intra-articular bupivacaine, 1 extracapsular bupivacaine) versus placebo, more than half reported that patients who received an intervention consumed significantly fewer opioids postoperatively than patients who received placebo (lowest P value = .0006). Of the same 7 studies, 2 reported significantly shortened LOS with interventions, while 4 reported no statistically significant difference in LOS and 1 did not report LOS as an outcome.

CONCLUSION

The majority of studies concerning adjunct analgesia for patients undergoing hip arthroscopy suggest benefits in pain reduction early in the postoperative period. There is mild evidence that adjunct analgesia reduces postoperative opioid use and currently inconclusive evidence that it reduces length of hospital stay. Furthermore, it appears that local infiltration analgesia may provide the greatest benefits in reductions in pain and opioid consumption. We recommend the use of adjunct analgesia in appropriately selected patients undergoing hip arthroscopy without contraindication who are at a high risk of severe postoperative pain.

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.

Fast Starters and Slow Starters After Hip Arthroscopy for Femoroacetabular Impingement: Correlation of Early Postoperative Pain and 2-Year Outcomes

BACKGROUND

Patients experience varying degrees of pain and symptoms during the early recovery period after hip arthroscopy for femoroacetabular impingement (FAI). Some "fast starters" report minimal discomfort and are eager to advance activities, while "slow starters" describe severe pain and limitations. The relationship between these early postoperative symptoms and 2-year outcomes after hip arthroscopy is unknown.

PURPOSE

To analyze the relationship between early postoperative pain and 2-year patient-reported outcomes (PROs) after hip arthroscopy for FAI.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Patients without arthritis or dysplasia who were undergoing primary hip arthroscopy for FAI were prospectively enrolled and completed validated PROs. Scores for visual analog scale (VAS) for pain were collected preoperatively and at 1 week, 6 weeks, and 2 years postoperatively. Scores for the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (HOOS), and 12-Item Short Form Health Survey (SF-12) were collected preoperatively and 2 years postoperatively. Paired t tests were used to evaluate PRO score changes, and correlation analyses were used to assess relationships between early postoperative pain and 2-year postoperative outcomes.

RESULTS

A total of 166 patients were included (55% female; mean ± SD age, 35.29 ± 9.6 years; mean body mass index, 25.07 ± 3.98 kg/m²). Patients demonstrated significant improvements in PRO scores (VAS, SF-12 Physical Component Score, mHHS, and all HOOS subscales) at 2 years after hip arthroscopy for FAI (P < .001). There was a significant correlation between lower 1-week VAS pain level (fast starters) and lower 2-year VAS pain level (R = 0.31; P < .001) as well as higher 2-year PRO scores (SF-12 Physical Component Score, mHHS, and all HOOS subscales: R = -0.21 to -0.3; P < .001). There was no correlation between 1-week VAS pain and 2-year SF-12 Mental Component Score (P = .17). Preoperative VAS pain levels showed positive correlations with 1-week postoperative pain scores (R = 0.39; P < .001) and negative correlations with 2-year patient outcomes (R = -0.15 to -0.33, P < .01). There was no correlation between 6-week postoperative pain scores and 2-year PRO scores.

CONCLUSION

Fast starters after hip arthroscopy for FAI experience sustained improvements in outcomes at 2 years after surgery. Patient pain levels before surgery may delineate potential fast starters and slow starters.

Responsiveness and ceiling effects of the English version of the 12-item International Hip Outcome Tool following hip arthroscopy at minimum one-year follow-up

AIMS

Responsiveness and ceiling effects are key properties of an outcome score. No such data have been reported for the original English version of the International Hip Outcome Tool 12 (iHOT-12) at a follow-up of more than four months. The aim of this study was to identify the responsiveness and ceiling effects of the English version iHOT-12 in a series of patients undergoing hip arthroscopy for intra-articular hip pathology at a minimum of one year postoperatively.

METHODS

A total of 171 consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement (FAI) under the care of a single surgeon between January 2013 and March 2017 were included. iHOT-12 and EuroQol 5D-5L (EQ-5D-5L) scores were available pre- and postoperatively. Effect size and ceiling effects for the iHOT-12 were calculated with subgroup analysis.

RESULTS

A total of 122 patients (71.3%) completed postoperative PROMs scores with median follow-up of 24.3 months (interquartile range (IQR) 17.2 to 33.5). The median total cohort iHOT-12 score improved significantly from 31.0 (IQR 20 to 58) preoperatively to 72.5 (IQR 47 to 90) postoperatively (p < 0.001). The effect size (Cohen's d) was 1.59. In all, 33 patients (27%) scored within ten points (10%) of the maximum score and 38 patients (31.1%) scored within the previously reported minimal clinically important difference (MCID) of the maximum score. Furthermore, nine (47%) male patients aged < 30 years scored within 10% of the maximum score and ten (53%) scored within the previously reported MCID of the maximum score.

CONCLUSION

There is a previously unreported ceiling effect of the iHOT-12 at a minimum one-year follow-up which is particularly marked in young, male patients following hip arthroscopy for FAI. This tool may not have the maximum measurement required to capture the true outcome following this procedure. Cite this article: Bone Joint J 2020;102-B(8):1010-1015.

Mismatch between expectations and physical activity outcomes at six months following hip-arthroscopy: A qualitative study

OBJECTIVE

To explore factors influencing participation in physical activity for young to middle-aged patients at six months post-hip arthroscopy.

DESIGN

Qualitative study.

SETTING

Three specialist surgical centres in Australia.

PARTICIPANTS

Seventeen adults aged 18-50 years.

MAIN OUTCOME MEASURES

Individual semi-structured interviews were undertaken and transcribed verbatum. Inductive analysis of the data was undertaken, with themes identified through an iterative coding process.

RESULTS

Four key themes emerged from the analysis: 1) an evident mismatch between expectations and actual progress of physical activity during the first six months post-arthroscopy; 2) physical activity levels vary widely at six months post-operatively; 3) evidence of suboptimal psychological readiness to return to sport and an associated emotional toll; and 4) the influence of available support and information on post-operative physical activity.

CONCLUSIONS

This qualitative study has provided in-depth perspectives on recovery after hip arthroscopy. Clear opportunities exist to: 1) help patients develop realistic post-operative goals; 2) provide timely patient education and support; and 3) facilitate an effective transition to desired physical activity.

There Is Limited and Inconsistent Reporting of Postoperative Rehabilitation for Femoroacetabular Impingement Syndrome: A Scoping Review of 169 Studies

OBJECTIVE

To evaluate the reporting of rehabilitation guidelines in studies of postoperative outcomes of patients with femoroacetabular impingement (FAI) syndrome and/or labral tear.

DESIGN

Scoping review.

LITERATURE SEARCH

A computer-assisted literature search was conducted of the MEDLINE, CINAHL, and Embase databases on June 17, 2018. Using key words related to FAI syndrome/labral tear and both open and arthroscopic surgical outcomes, we identified 169 studies that included 16 675 patients. Separate authors calculated and verified the prevalence of reported outcomes.

STUDY SELECTION CRITERIA

We included intervention and observational studies that were prospective or retrospective in design. Studies must have included patients with a primary diagnosis of FAI syndrome and/or labral tear.

DATA SYNTHESIS

We calculated the mean ± SD prevalence for continuous variables, where possible.

RESULTS

Hip arthroscopy was the primary surgical procedure (76% of studies). The mean ± SD age of participants was 34.8 ± 9.2 years and the mean ± SD follow-up time was 27 ± 15.3 months. Of the 169 included studies, 74 (44%) discussed phases of rehabilitation, 49 (29%) reported details on goals between phases, 1 in 3 described details on rehabilitation progression, and fewer than 1 in 10 reported sufficient detail to replicate the rehabilitation protocol. Weight-bearing and range-of-motion restrictions were poorly reported and variable in duration.

CONCLUSION

Surgical outcome studies do not provide sufficient detail or consistency for practicing clinicians to replicate a postoperative rehabilitation protocol for patients with FAI syndrome/labral tear. J Orthop Sports Phys Ther 2020;50(5):252-258. doi:10.2519/jospt.2020.9189.

Despite patient-reported outcomes improve, patients with femoroacetabular impingement syndrome do not increase their objectively measured sport and physical activity level 1 year after hip arthroscopic surgery. Results from the HAFAI cohort

PURPOSE

Patients with femoroacetabular impingement syndrome (FAIS) are young and middle-aged persons living physically active lives including sports activities. However, measurements of the physical activity level before and after hip arthroscopic surgery in patients with FAIS using both self-reported and objective accelerometer-based measures are lacking. Furthermore, comparing patients with a reference group of persons reporting no hip problems and conducting subgroup analyses investigating changes in physical activity level and self-reported outcomes according to pre-surgery activity level may further highlight the activity pattern for patients.

METHODS

Sixty patients with FAIS eligible for hip arthroscopic surgery were consecutively included in a prospective cohort study (HAFAI cohort) together with 30 reference persons reporting no hip problems. Participants completed the Copenhagen Hip and Groin Outcome Score (HAGOS) together with questions regarding their sports activities. Furthermore, participants wore a three-axial accelerometer for five consecutive days during waking hours. The accelerometer-based data were analysed and presented as total activity and type, frequency and duration of activities.

RESULTS

Patients experienced significant and clinically relevant changes in all HAGOS scores. 88% of patients participated in some kind of sports activity 1 year after surgery. Overall, objectively measured physical activity did not change from before to 1 year after surgery. However, subgroup analyses of the most sedentary patients preoperatively revealed significant changes towards a more active pattern. Compared to reference persons, patients performed less bicycling and running.

CONCLUSION

Despite clinically relevant changes in self-reported outcomes, patients did not increase their overall physical activity level 1 year after surgery. Physical activity levels were lower in patients than in the reference group and patients continued bicycling and running less compared with the reference group.

LEVEL OF EVIDENCE

II.

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.

Effectiveness of Hip Arthroscopy on Treatment of Femoroacetabular Impingement Syndrome: A Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

To appraise the highest available evidence provided by randomized controlled trials (RCTs) on the effectiveness of hip arthroscopy versus physical therapy in patients with femoroacetabular impingement syndrome (FAIS).

METHODS

Four databases (Medline, Embase, Web of Science, and Scopus) were systematically searched until October 1, 2019. Eligible studies were RCTs in which patients with FAIS underwent hip arthroscopy or physical therapy. The study outcome was the International Hip Outcome Tool, 33 Items (iHOT-33) score, a measure of hip pain, function, and quality of life, assessed at baseline and at the follow-up closer to 12 months after randomization. The pooled mean difference in iHOT-33 scores within and between the treatment arms was computed using a random effects model. The minimum clinically important difference in the iHOT-33 scores was set at 10 points.

RESULTS

Three RCTs evaluating iHOT-33 scores between 6 and 8 months after the interventions were included. Significant increases in iHOT-33 scores were observed from baseline to follow-up for both hip arthroscopy (22.3 points [95% confidence interval (95% CI) 17.3-27.4]) and physical therapy (13.0 points [95% CI 9.5-16.4]). Hip arthroscopy demonstrated significantly higher iHOT-33 scores at follow-up compared with physical therapy (10.9 points [95% CI 4.7-17.0]).

CONCLUSION

Both hip arthroscopy and physical therapy resulted in statistically and clinically significant short-term improvements in hip pain, function, and quality of life in patients with FAIS. Hip arthroscopy was statistically superior to physical therapy in improving the outcome at follow-up even if improvement may not be detected by patients.

No association between femoral or acetabular angles and patient-reported outcomes in patients with femoroacetabular impingement syndrome-results from the HAFAI cohort

Patients with femoroacetabular impingement syndrome (FAIS) are diagnosed using imaging, but detailed description especially the acetabular shape is lacking and may help give more insight to the pathogenesis of FAIS. Furthermore, associations between patient-reported outcomes (PROs) and the radiological angles might highlight which radiological angles affect outcomes experienced by the patients. Hence, the aims of this study were (i) to describe computer tomography (CT) acquired angles in patients with FAIS and (ii) to investigate the association between radiological angles and the Copenhagen Hip and Groin Outcome Score (HAGOS) in patients with FAIS. Patients scheduled for primary hip arthroscopic surgery for FAIS were included. Based on CT, following angles were measured before and 1 year after surgery; femoral anteversion, alpha, lateral centre edge, acetabular index, anterior sector, posterior sector and acetabular anteversion. All patients completed the HAGOS. Sixty patients (63% females) aged 36 ± 9 were included. One year after surgery, significant alterations in the alpha angle and the acetabular index angle were found. Neither baseline PROs nor changes in PROs were associated with the radiological angles or changes in angles. Since neither changes in CT angles nor baseline scores were associated with HAGOS, the improvements felt by patients must origin from somewhere else. These findings further underlines that morphological changes seen at imaging should not be treated arthroscopically without a patient history of symptoms and clinical findings.

Defining Variations in Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Using the 12-Item International Hip Outcome Tool (iHOT-12)

BACKGROUND

As health care moves toward a value-based payment system, it will be important that patient-reported outcome measures (PROMs) define variations in outcome over a follow-up period that allows a patient to achieve maximal improvement. Although there is evidence to support the use of PROMs to assess postoperative outcomes after hip arthroscopy, there is limited information available to assess for variations in outcome at a 2-year follow-up interval.

PURPOSE

To identify substantial clinical benefit (SCB) and patient acceptable symptom state (PASS) cutoff scores for the 12-item International Hip Outcome Tool (iHOT-12) that define patient status across a spectrum of potential outcomes after hip arthroscopy at a 2-year follow-up interval.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

These data were collected from a research registry of patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and 2 years (±2 months) postoperatively, patients completed the iHOT-12, and categorical self-rating of function. They also completed a visual analog scale of postoperative satisfaction. Receiver operator characteristic analysis was performed to determine absolute SCB iHOT-12 scores associated with an "abnormal,""nearly normal," or "normal" self-report of function, and PASS scores for those reporting at least 50%, at least 75%, or 100% satisfaction with their surgery.

RESULTS

Out of 723 eligible patients, 658 (91%) met the inclusion criteria. The patients consisted of 462 (70%) women and 196 (30%) men, with a mean age of 35.3 years (SD, 13 years) and mean follow-up of 722 days (SD, 69 days). Absolute SCB and PASS iHOT-12 scores ranging from 38 to 86 were accurate in identifying those who had abnormal, nearly normal, and normal self-reported function and were at least 50%, at least 75%, and 100% satisfied with surgery. The areas under the curve were >0.70, with sensitivity and specificity values ranging from 0.78 to 0.92.

CONCLUSION

This study provides absolute SCB and PASS iHOT-12 cutoff scores that can be used to define variations in 2-year (±2 months) outcomes in patients after hip arthroscopy for femoroacetabular impingement and chondrolabral pathology. iHOT-12 scores of 38, 60, and 86 were associated with abnormal, nearly normal, and normal reports of function respectively, with scores of 60, 71, and 86 associated with at least 50%, at least 75%, and 100% satisfaction after surgery, respectively.

Labral calcification plays a key role in hip pain and symptoms in femoroacetabular impingement

BACKGROUND

Hip osteoarthritis (HOA) is the most common hip disorder and a major cause of disability in the adult population, with an estimated prevalence of end-stage disease and total hip replacement. Thus, the diagnosis, prevention, and treatment of the early stages of the disease in young adults are crucial to reduce the incidence of end-stage HOA. The purpose of this study was to determine whether (1) a relationship among the inflammatory status of labrum and synovium collected from patients with femoroacetabular impingement (FAI) would exist; and (2) to investigate the associations among the histopathological features of joint tissues, the pre-operative symptoms and the post-operative outcomes after arthroscopic surgery.

METHODS

Joint tissues from 21 patients undergoing hip arthroscopy for FAI were collected and their histological and immunohistochemical features were correlated with clinical parameters.

RESULTS

Synovial mononuclear cell infiltration was observed in 25% of FAI patients, inversely correlated with the hip disability and osteoarthritis outcome score (HOOS) pain and function subscales and with the absolute and relative change in total HOOS. All the labral samples showed some pattern of degeneration and 67% of the samples showed calcium deposits. The total labral score was associated with increased CD68 positive cells in the synovium. The presence of labral calcifications, along with the chondral damage worsened the HOOS post-op symptoms (adjusted R-square = 0.76 p = 0.0001).

CONCLUSIONS

Our study reveals a relationship between the histologic labral features, the synovial inflammation, and the cartilage condition at the time of FAI. The presence of labral calcifications, along with the cartilage damage and the synovitis negatively affects the post-operative outcomes in patients with FAI.

A tiered system using substantial clinical benefit and patient acceptable symptomatic state scores to evaluate 2-year outcomes of hip arthroscopy with the Hip Outcome Score

There is no information to define variations in hip arthroscopy outcomes at 2-year follow-up using the Hip Outcome Score (HOS). To offer a tiered system using HOS absolute substantial clinical benefit (SCB) and patient acceptable symptomatic state (PASS) scores for 2-year hip arthroscopy outcome assessment. This was a retrospective review of patients having hip arthroscopy for femoroacetabular impingement and/or chondrolabral pathology. On initial assessment and 2 years (±2 months) post-operatively, subjects completed the HOS activity of daily living (ADL) and Sports subscales, categorical self-rating of function and visual analog scale for satisfaction with surgery. Receiver operator characteristic analysis identified absolute SCB and PASS HOS ADL and Sports subscale scores. Subjects consisted of 462 (70%) females and 196 (30%) males with a mean age of 35.3 years [standard deviation (SD) 13] and mean follow-up of 722 days (SD 29). SCB and PASS scores for the HOS ADL and Sports subscales were accurate in identifying those at a ‘nearly normal’ and ‘normal’ self- report of function and at least 75% and 100% levels of satisfaction (area under the curve >0.70). This study provides tiered SCB and PASS HOS scores to define variations in 2-year (±2 months) outcome after hip arthroscopy. HOS ADL subscale scores of 84 and 94 and Sports subscale scores of 61 and 87 were associated with a ‘nearly normal’ and ‘normal’ self-report of function, respectively. HOS ADL subscale scores of 86 and 94 and Sports subscale score of 74 and 87 were associated with being at least 75% and 100% satisfied with surgery, respectively. Level of evidence: III, retrospective comparative study.

Psychometric Properties of the Hip-Return to Sport After Injury Scale (Short Form) for Evaluating Psychological Readiness to Return to Sports After Arthroscopic Hip Surgery

BACKGROUND

Successful return to sports activity after surgery requires both physical and psychological readiness. The Hip-Return to Sport After Injury (Short Form) has been developed to assess psychological readiness to return to sports after hip injury and hip surgery, including hip arthroscopy.

PURPOSE

To evaluate the reliability, validity, responsiveness, and interpretability of the scale for a cohort of patients after hip arthroscopy with a range of sports participation levels.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Invitations to participate were sent to 145 patients from 3 specialist surgeons. The study included 77 participants 1 to 24 months after hip arthroscopy (mean ± SD age, 35 ± 9 years; 62% women) and 33 healthy age-matched controls (age, 37 ± 7 years; 52% women). The scale was administered electronically on 3 occasions to patients: baseline (≥1 month postarthroscopy), 1 week later, and 6 months later. In addition to the scale, participants were asked about sports participation status and their global rating of postsurgical change. The scale was administered to healthy controls on 1 occasion. The minimal detectable difference, discriminant validity, floor and ceiling effects, responsiveness, and interpretability (minimally important change) were determined for the scale.

RESULTS

Among the postarthroscopy group, excellent test-retest reliability was found (intraclass correlation coefficient = 0.869; 95% CI, 0.756-0.932) with a minimal detectable difference of 26 points out of 100 at the individual level and 4 points out of 100 at the group level. At baseline discriminant validity was evident between those who had returned to sports (median = 69, n = 35) and those who had not returned to sports (median = 30, n = 42; Mann-Whitney U score = 232.5, z = -5.141, P < .001) and between the returned-to-sports postarthroscopy group and healthy controls (median = 96, n = 33; Mann-Whitney U score = 165.500, z = 5.666, P < .001). No floor or ceiling effects were evident. Responsiveness was demonstrated for the scale in relation to sports status. With sports status as an anchor, a minimally important change of 26 points was identified.

CONCLUSION

Assessment of the Hip-Return to Sport After Injury (Short Form) supports its use as a reliable and valid measure of psychological readiness to return to sports in patients after hip arthroscopy.

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

Standardised measurement of physical capacity in young and middle-aged active adults with hip-related pain: recommendations from the first International Hip-related Pain Research Network (IHiPRN) meeting, Zurich, 2018

Hip-related pain can significantly impact quality of life, function, work capacity, physical activity and family life. Standardised measurement methods of physical capacity of relevance to young and middle-aged active adults with hip-related pain are currently not established. The aim of this consensus paper was to provide recommendations for clinical practice and research on standardised measurement methods of physical capacity in young and middle-aged active adults with hip-related pain. Four areas of importance were identified: (1) clinical measures (range of motion, muscle strength, functional impairments), (2) laboratory-based measures (biomechanics and muscle function (muscle activity, size and adiposity)), (3) physical activity, and (4) return to sport/performance. The literature was reviewed, and a summary circulated to the working group to inform discussion at the consensus meeting. The working group developed clinical and research recommendations from the literature review, which were further discussed and modified within the working group at the consensus meeting. These recommendations were then presented to all 38 International Hip-related Pain Research Network (IHiPRN) participants for further discussion, refinement and consensus voting. Therefore, the recommendations voted on were based on a combination of current evidence and expert opinion. The consensus meeting voted on 13 recommendations, six of which were clinically orientated, and seven more research specific. We recommended that clinicians working with young and middle-aged active adults with hip-related pain assess strength using objective methods of measurement, and clinically assess performance of functional tasks, including walking and running. Physical activity should be quantified using both self-reported and objective measures, and patient expectations of recovery should be quantified prior to treatment. It was recommended that return to physical activity (including sport and occupation) be quantified, and sport-specific activities should be assessed prior to return to sport. The IHiPRN participants were uncertain regarding recommendations for range of motion assessment. Research recommendations were that the measurement properties of range of motion, strength and functional performance tests be investigated, reported and improved in both clinical and research settings. Reporting of movement-related parameters (biomechanics and muscle function) should be standardised and the relationship among movement-related parameters, symptoms, function, quality of life, and intra-articular and imaging findings should be investigated. Quantification of return to physical activity (including sport and occupational demands) is required in future research, and the return to sport continuum should be used. Future research is required to determine the best criteria for rehabilitation progression and return to physical activity following hip-related pain management.

Physiotherapist-led treatment for young to middle-aged active adults with hip-related pain: consensus recommendations from the International Hip-related Pain Research Network, Zurich 2018

The 1st International Hip-related Pain Research Network meeting discussed four prioritised themes concerning hip-related pain in young to middle-aged adults: (1) diagnosis and classification of hip-related pain; (2) patient-reported outcome measures for hip-related pain; (3) measurement of physical capacity for hip-related pain; (4) physiotherapist-led treatment for hip-related pain. Thirty-eight expert researchers and clinicians working in the field of hip-related pain attended the meeting. This manuscript relates to the theme of physiotherapist-led treatments for hip-related pain. A systematic review on the efficacy of physiotherapist-led interventions for hip-related pain (published separately) was conducted and found that strong evidence for physiotherapist-led treatments was lacking. Prior to the meeting, draft consensus recommendations for consideration in the meeting were also developed based on the systematic review. The draft consensus recommendations were presented to all of the meeting participants via email, at least 1 week prior to the meeting. At the meeting, these recommendations were discussed, revised and voted on. Six recommendations for clinical practice and five recommendations for research were included and all gained consensus. Recommendations for clinical practice were that (i) Exercise-based treatments are recommended for people with hip-related pain. (ii) Exercise-based treatment should be at least 3 months duration. (iii) Physiotherapist-led rehabilitation after hip surgery should be undertaken. (iv) Patient-reported outcome measures, measures of physical impairment and measures of psychosocial factors should be used to monitor response to treatment. (v) Physical activity (that may include sport) is recommended for people with hip-related pain. (vi) Clinicians should discuss patient expectations, use shared-decision making and provide education. Recommendations for research were (i) Reporting of exercise programmes: Exercise descriptors such as load magnitude, number of repetitions and sets, duration of whole programme, duration of contractile element of exercise, duration of one repetition, time under tension, rest between repetitions, range of motion through which the exercise is performed, and rest between exercise sessions should be reported. (ii) Research should investigate the optimal frequency, intensity, time, type, volume and progression of exercise therapy. (iii) Research should examine the effect of patient education in people with hip-related pain. (iv) Research should investigate the effect of other treatments used in people with hip-related pain (for example: manual therapy, medications, injections). (v) Research should examine the impact of comorbidities and social determinants on treatment effectiveness in people with hip-related pain. Clinicians and researchers working with young to middle-aged active adults with hip-related pain may use these consensus recommendations to guide, develop, test and implement individualised, evidence-based physiotherapist-led rehabilitation programmes.