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

Ultrasound-Guided Hip Injections with High Density Hyaluronic Acid: Outcome at One Year Follow Up

Background: The ultrasound-guided viscosupplementation of the hip joint with hyaluronic acid (HA) is considered a standard procedure among the conservative treatments for hip arthritis. The aim of this study was to evaluate the clinical benefit and the incidence of adverse events of the technique in an observational study at one year follow up. Methods: We evaluated a consecutive series of 85 patients with a diagnosis of symptomatic arthritis who underwent intra-articular ultrasound-guided hyaluronic acid injections. The scales used for evaluation were modified Harris Hip Score (mHHS), WOMAC (Western Ontario and McMaster University), and Hip Outcome Score (HOS) with subscale Sport (HOSs), for pain the Visual Analogic Scale (VAS). The patients were classified according to Tonnis' radiological classification of arthritis (range 0-3): 20 patients (grade 0), 32 (grade 1), 18 (grade 2), 15 (grade 3). Results: At last follow up, all the scales increased: mHHS from 59.35 to 82.1, HOS from 69.45 to 78.53, HOss from 47.4 to 58.11, VAS from 6.09 to 3.97, WOMAC from 33.2 to 31.5 (p < 0.05 for all the parameters); the results were elaborated with GraphPad Prism v5.0 (Prism Software La Jolla, CA, USA) using Wilcoxon's test. A total of 13 patients out of 85 needed arthroplasty, all classified as Tonnis grade 3. No serious adverse events were noted due to the procedure. Conclusions: Based on our findings, indication for the use of hyaluronic acid is limited to patients with mild to moderate arthritis. Patients in advanced arthritis refusing replacement surgery and asking for this treatment should be informed about the poor results of the technique even in the short term.

Hip and Pelvis Movement Patterns in Patients With Femoroacetabular Impingement Syndrome Differ From Controls and Change After Hip Arthroscopy During a Step-Down Pivot-Turn Task

Background

Alterations in hip kinematics during functional tasks occur in positions that cause anterior impingement in patients with femoroacetabular impingement (FAI) syndrome. However, tasks that do not promote motions of symptomatic hip impingement remain understudied.

Purpose

To compare movement patterns of the hip and pelvis during a step-down pivot-turn task between patients with FAI and controls as well as in patients with FAI before and after hip arthroscopy.

Study Design

Controlled laboratory study.

Methods

Three-dimensional motion capture was acquired in 32 patients with FAI and 27 controls during a step-down pivot-turn task. An FAI subsample (n = 14) completed testing 9.2 ± 2.0 months (mean ± SD; range, 5.8-13.1 months) after hip arthroscopy. Statistical parametric mapping analysis was used to analyze hip and pelvis time series waveforms (1) between the FAI and control groups, (2) in the FAI group before versus after hip arthroscopy, and (3) in the FAI group after hip arthroscopy versus the control group. Continuous parametric variables were analyzed by paired t test and nonparametric variables by chi-square test.

Results

There were no significant differences in demographics between the FAI and control groups. Before hip arthroscopy, patients with FAI demonstrated reduced hip flexion (P = .041) and external rotation (P = .027), as well as decreased anterior pelvic tilt (P = .049) and forward rotation (P = .043), when compared with controls. After hip arthroscopy, patients demonstrated greater hip flexion (P < .001) and external rotation of the operative hip (P < .001), in addition to increased anterior pelvic tilt (P≤ .036) and pelvic rise (P≤ .049), as compared with preoperative values. Postoperatively, the FAI group demonstrated greater hip flexion (P≤ .047) and lower forward pelvic rotation (P = .003) as compared with the control group.

Conclusion

Movement pattern differences between the FAI and control groups during the nonimpingement-related step-down pivot-turn task were characterized by differences in the sagittal and transverse planes of the hip and pelvis. After hip arthroscopy, patients exhibited greater hip flexion and external rotation and increased pelvic anterior tilt and pelvic rise as compared with presurgery. When compared with controls, patients with FAI demonstrated greater hip flexion and lower pelvic forward rotation postoperatively.

Clinical Relevance

These findings indicate that hip and pelvis biomechanics are altered even during tasks that do not reproduce the anterior impingement position.

Outcomes After Hip Arthroscopy Show No Differences Between Sexes: A Systematic Review

PURPOSE

To assess differences in postoperative outcomes between male and female patients following hip arthroscopy.

METHODS

A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Cochrane, and PubMed databases were searched. Key words included "hip," "arthroscopy," "outcome," "gender difference," "sex difference," "gender," and "patient-reported outcome." Studies were included that reported sex-specific analysis of outcomes following primary hip arthroscopy with minimum 2-year follow-up. Methodological Index for Non-Randomized Studies criteria were applied to each study. Data collected included patient-reported outcome measures (PROMs), complications, rates of revision arthroscopy (RA), and conversion to total hip arthroplasty (THA). Forest plots were generated for the most frequently reported PROMs, RA, and THA rates.

RESULTS

In total, 38 studies met the inclusion criteria, with 40,194 (57% female) hips included. The most common indications for hip arthroscopy were femoroacetabular impingement and labral tears. Eighteen studies reported PROMs, with no clear trend towards sex differences. Eleven studies reported on RA rates, with 4 showing a significantly greater rate of RA in female patients. Seventeen studies reported on conversion to THA, with an overall conversion rate of 9.64%. There were no clear sex differences in conversion to THA.

CONCLUSIONS

There was no difference between sexes for postoperative PROM scores. Male patients were less likely to reach the MCID for the HOS-SSS than female patients in the majority of studies, and there were no sex differences for PASS rates. There were no significant differences between sexes in revision arthroscopy rates and conversion to total hip arthroplasty.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III and IV studies.

A Smartphone App Shows Patients Return to Preoperative Gait Metrics 6 Weeks After Hip Arthroscopy, and Gait Metrics Have Low to Moderate Correlations With a Hip-Specific Patient-Reported Outcome Measure

Purpose

The purpose of this study was to use a smartphone app to collect gait metrics in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and determine when gait metrics return to preoperative levels and if gait metrics correlate with postoperative hip-specific patient-reported outcomes.

Methods

Patients undergoing primary hip arthroscopy for FAIS from August 2021 to December 2022 were prospectively enrolled. Patients downloaded the iPhone app, rHip, at ∼6 months postoperatively, enabling retroactive access to Apple Health data. Gait metrics included step count, step length, and walking speed. Each patient's preoperative baseline was compared to that individual's successive postoperative week metrics. All patients underwent a standard 4-stage rehabilitation protocol. We compared metrics from beginning to end of each phase (i.e., week 1 to 6 for phase 1) and evaluated correlations with patient outcomes.

Results

Fifty patients (40 women; age: 31.9 ± 14.5 years) were included. Patients had significantly reduced step count from postoperative weeks 1 to 5 and improved upon baseline at weeks 13 and 16 to 26. Patients had significantly reduced step length from postoperative weeks 1 to 4 and improved upon baseline at weeks 16 and 20. Patients had significantly lower walking speed from postoperative weeks 1 to 6 and improved upon baseline at week 20 (P < .05). Step count significantly improved over phase 1 rehabilitation (P < .05). Step length and walking speed significantly improved over each of phases 1 to 3 (P < .05 for all). Preoperatively, weak correlations were noted between step length and Patient-Reported Outcomes Measurement Information System (PROMIS) for Physical Function (PF)/Pain, as well as walking speed and Hip Outcome Score-Activities of Daily Living (HOS-ADL)/PROMIS-Pain. At 3 months, moderate correlations were noted between step count and HOS-ADL/12-item international Hip Outcome Tool (iHOT-12), step length and HOS-ADL/PROMIS-PF, and walking speed and HOS-ADL/iHOT-12/PROMIS-PF/PROMIS-Pain. At 6 months, weak to moderate correlations were noted between all 3 gait metrics and HOS-ADL.

Conclusions

A smartphone app was capable of capturing health data gait metrics. Patients undergoing hip arthroscopy for FAIS returned to baseline levels in step count, step length, and walking speed after phase 1 (6 weeks) of rehabilitation. The most consistent correlations between gait metrics and step count were seen at 3 months, although only weak to moderate. Gait metrics similarly had weak to moderate correlations with HOS-ADL at 6 months.

Level of Evidence

Level IV, case series.

Sex-Based Differences in Prevalence, Outcomes, and Complications of Hip Arthroscopy for Femoroacetabular Impingement: A Systematic Review and Meta-analysis

Background

Trends between the sexes have been reported regarding prevalence, patient-reported outcomes (PROs), and complications of hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS), yet current results lack consensus.

Purpose

To evaluate sex-based differences after HA for FAIS in (1) prevalence of cam and pincer morphology in FAIS and (2) PROs, pain scores, and postoperative complication rates.

Study Design

Systematic review; Level of evidence, 4.

Methods

The EMBASE, PubMed, and Ovid (MEDLINE) databases were searched from establishment to February 28, 2022, according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Included studies had sex-based data on prevalence, outcomes, and complications of HA for FAIS. Reviews and commentaries were excluded. Data were combined, and between-sex differences were analyzed. Meta-analyses using random-effects models were performed when possible. Pooled risk ratios (RRs) and standardized mean differences were calculated.

Results

A total of 74 studies were included (213,059 patients; 132,973 female hips [62.4%] and 80,086 male hips [37.6%]). The mean age was 30.7 ± 7.7 years among male patients and 31.1 ± 7.8 years among female patients. Male patients experienced mixed-type impingement significantly more often (39.4% vs 27.2% for female patients; RR = 0.69 [95% confidence interval [CI], 0.58-0.81]; P < .001), whereas female patients experienced pincer-type impingement more often (50.6% vs 30.8% for male patients; RR = 2.35 [95% CI, 1.14-4.86]; P = .02). Male patients had higher likelihoods of undergoing femoroplasty (89.8% vs 77.4% for female patients; RR = 0.90 [95% CI, 0.83-0.97]; P = .006), acetabuloplasty (67.1% vs 59.3% for female patients; RR = 0.87 [95% CI, 0.79-0.97]; P = .01), or combined femoroplasty/acetabuloplasty (29.2% vs 14.5% for female patients; RR = 0.63 [95% CI, 0.44-0.90]; P = .01). Although female patients showed greater improvements in Hip Outcome Score-Sport-Specific subscale (P = .005), modified Harris Hip Score (P = .006), and visual analog scale pain (P < .001), both sexes surpassed the minimal clinically important difference at 1, 2, and 5 years postoperatively. Female patients had higher complication rates (P = .003), although no sex-based differences were found in total hip arthroplasty conversion rates (P = .21).

Conclusion

Male patients undergoing HA for FAIS had a higher prevalence of mixed-type FAIS while female patients had more pincer-type FAIS. Female patients gained greater improvements in PROs, although both sexes exceeded the minimal clinically important difference, suggesting that both male and female patients can benefit from HA.

Recovery After Hip Arthroscopy in Patients With Combined Femoroacetabular Impingement and Labral Tears Compared With Isolated Pathology

Background

Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology.

Purpose

To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT-12).

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT-12 scores at 1.5, 3, 6, 12, 18, and >24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS).

Results

Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT-12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) (P < .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively (P < .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively.

Conclusion

The final iHOT-12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau.

Patients Follow 3 Different Rate-of-Recovery Patterns After Anterior Cruciate Ligament Reconstruction Based on International Knee Documentation Committee Score

PURPOSE

To determine whether subgroups of patients exist based on the rate-of-recovery pattern of International Knee Documentation Committee (IKDC) scores after anterior cruciate ligament reconstruction (ACLR) and to determine clinical predictors for these subgroups.

METHODS

Patients who underwent primary or revision ACLR at a single institution from January 2014 to January 2019 were identified. Latent class growth analyses and growth mixture models (GMMs) with 1 to 6 classes were used to identify subgroups of patients based on functional rate-of-recovery patterns by use of preoperative, 1-year postoperative, and 2-year postoperative IKDC scores.

RESULTS

A total of 245 patients who underwent ACLR were included in the analysis. A 3-class GMM was chosen as the final model after 6 different models were run. Class 1, showing improvement from preoperatively to 1-year follow-up, with sustained improvement from 1 to 2 years postoperatively, constituted 77.1% of the study population (n = 189), whereas class 2, showing functional improvement between 1- and 2-year follow-up, was the smallest class, constituting 10.2% of the study population (n = 25), and class 3, showing slight improvement at 1-year follow-up, with a subsequent decline in IKDC scores between 1- and 2-year follow-up, constituted 12.7% of the study population (n = 31). Revision surgery (P = .005), a psychiatric history (P = .025), preoperative chronic knee pain (P = .024), and a subsequent knee injury within the follow-up period (P = .011) were the predictors of class 2 and class 3 rate-of-recovery patterns. Patient demographic characteristics, graft type, and concomitant ligament, meniscus, or cartilage injury at the time of surgery were not associated with the different recovery patterns described in this study.

CONCLUSIONS

Patients may follow different rate-of-recovery patterns after ACLR. By use of the GMMs, 3 different rate-of-recovery patterns based on IKDC scores were identified. Although most patients follow a more ideal rate-of-recovery pattern, fewer patients may follow less favorable patterns. Revision surgery, a history of psychiatric illness, preoperative chronic knee pain, and a subsequent knee injury within the follow-up period were predictive of less favorable rate-of-recovery patterns.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.