Association Between Chondrolabral Junction Breakdown and Conversion to Total Hip Arthroplasty After Hip Arthroscopy for Symptomatic Labral Tears: Minimum 8-Year Follow-up

Patients Undergoing Hip Arthroscopy for Acetabular Labral Treatment from Neighborhoods with Greater Socioeconomic Disadvantage Experience Worse Healthcare Accessibility, Inferior Mid-Term Functional Outcomes, and Similar Rates of Conversion to Total Hip Arthroplasty

PURPOSE

To investigate the effects of neighborhood-level socioeconomic disadvantage on healthcare accessibility and mid-term functional outcomes for patients undergoing primary hip arthroscopy for the treatment of acetabular labral tears.

METHODS

This retrospective analysis queried patients ≥18 years old who underwent primary hip arthroscopy for treatment of symptomatic labral tears secondary to femoroacetabular impingement syndrome, had complete patient-reported outcome measures (PROMs) at minimum 8-year follow-up, and resided in the United States. All patients underwent surgery between May 2001 and September 2013. Utilizing the Area Deprivation Index (ADI) to quantify neighborhood-level socioeconomic disadvantage, patients were divided into quartiles. Those in the least and most disadvantaged quartiles represented the ADILow and ADIHigh cohorts, respectively. Healthcare accessibility and socioeconomic disadvantage were compared between cohorts using rural, health professional shortage area (HPSA), medically underserved area/population (MUA/P), insurance status, education level, and household income classifications. Collected patient-reported outcome measures (PROMs) included the modified Harris Hip Score (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (HOS-ADL), HOS-Sports Specific Subscale (HOS-SSS), Nonarthritic Hip Score (NAHS), 33-item International Hip Outcome Tool (iHOT-33), and rates of conversion to total hip arthroplasty (THA).

RESULTS

The ADILow (ADI: 4.0±2.1) and ADIHigh (ADI: 37.7±12.1) cohorts each consisted of 43 patients. A greater proportion of ADIHigh patients resided in rural communities (P=0.026), primary care HPSAs (P=0.024), and MUA/Ps (P=0.019). At a patient level, the ADIHigh cohort had lower levels of insurance coverage (P=0.035), education (P=0.002), and household income (P=0.002). Finally, ADIHigh patients achieved worse functional outcome scores for mHHS (P=0.008), NAHS (P=0.043), HOS-ADL (P=0.020), and iHOT-33 (P=0.041). By multivariate logistic regression, ADIHigh patients were nearly 11.4 and 10.4 times less likely to achieve the 10-year patient acceptable symptom state for mHHS (OR, 0.09; P=0.008) and HOS-ADL (OR, 0.10; P=0.018), respectively. Despite having significantly worse PROMs, ADIHigh patients underwent statistically similar rates of revision hip arthroscopy (ADIHigh: 7.0% vs. ADILow: 4.7%; P=0.645) and conversion to THA (ADIHigh: 11.6% vs. ADILow: 20.9%; P=0.213).

CONCLUSIONS

Patients undergoing hip arthroscopy for acetabular labral treatment from neighborhoods with greater ADI scores experience worse healthcare accessibility, inferior mid-term functional outcomes, and similar rates of conversion to THA.

LEVEL OF EVIDENCE

Retrospective Cohort; LOE 3.

Procedure Type and Preoperative Patient-Reported Outcome Metrics Predict Variation in the Value of Hip Arthroscopy for Femoroacetabular Impingement

Purpose

To characterize variation in the value of hip arthroscopy for femoroacetabular impingement and explore associations between value and patient-specific demographic characteristics, comorbidities, preoperative patient-reported outcome measures (PROMs), and intraoperative variables.

Methods

We included all patients aged 18 years or older who underwent primary arthroscopic acetabular labral repair or debridement between 2015 and 2020 with minimum 2-year follow-up. The exclusion criteria were hip dysplasia, advanced hip osteoarthritis (TÖnnis grade >1), or unreconcilable documenting errors. Value was calculated by dividing 2-year postoperative International Hip Outcome Tool 33 scores by time-driven activity-based costs. To protect the confidentiality of internal hospital cost data, the study average for value was normalized to 100. Multivariable linear mixed-effects models were used to identify factors underlying variation in value.

Results

This study included 161 patients. There were 76 women (47.2%) and 85 men, with a mean age of 36.0 years (standard deviation [SD], 10.9 years) and mean body mass index (BMI) of 25.8 (SD, 4.3). Most patients were white (92.5%), were not Hispanic (93.8%), and were commercially insured (92.5%). Preoperatively, 57.1% of hips were classified as Tönnis grade 1 (57.1%) whereas the remainder were grade 0. The normalized value of hip arthroscopy ranged from 25.4 to 216.4 (mean ± SD, 100 ± 38.4), with a 3.0-fold variation between patients in the 10th and 90th percentiles. Higher value was significantly associated with Tönnis grade 0 (12.2-point increase, P = .025), no prior contralateral hip arthroscopy (17.3-point increase, P = .039), higher preoperative PROMs (0.52-point increase per 1-unit increase, P < .001), and no bone marrow aspirate concentrate or microfracture (33.8-point increase, P < .001). Value was also significantly associated with osteoplasty type and labral treatment technique (P < .05 for both). In contrast, operative year, age, sex, BMI, race, ethnicity, Outerbridge grade, and American Society of Anesthesiologists score were not independently associated with value. A model incorporating these factors as fixed effects and the surgery center as a random effect explained 42.3% of the observed variation in value. Sensitivity analyses revealed that value drivers may vary slightly across PROMs.

Conclusions

This study revealed wide variation in the value of hip arthroscopy that was most strongly explained by osteoplasty type, labral management technique, and preoperative PROMs. In contrast, patient demographic characteristics such as age, sex, and BMI contributed minimal independent variability.

Level of Evidence

Level IV, economic and decision analysis.

The Impact of Hip Arthroscopy on the Progression of Hip Osteoarthritis in Patients With Femoroacetabular Impingement Syndrome: A Systematic Review and Meta-analysis

Background

Hip arthroscopy (HA) for the surgical management of femoroacetabular impingement syndrome (FAIS) provides reliable improvements in pain and function; however, debate remains regarding the impact of HA on the progression of osteoarthritis (OA).

Purpose

To determine whether HA for FAIS reduces the progression of OA and the risk of conversion to total hip arthroplasty (THA).

Study Design

Systematic review; level of evidence, 4.

Methods

A systematic electronic search of articles in Medline, Embase, and ClinicalTrials.gov databases was performed under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, with 5046 articles remaining after duplicates were removed. All papers addressing HA for FAIS that reported radiographic progression of hip OA with a follow-up of ≥2 years were eligible for inclusion. Studies assessing labral reconstruction, revision HA, case reports, studies with <10 patients, and patients with hip dysplasia or rheumatoid arthritis were excluded. A total of 322 studies progressed to full text, and 16 studies were ultimately included in this review. Studies were divided based on short-term (ST) (2 to <5 years), mid-term (MT) (5 to <10 years), and long-term (LT) (>10 years) follow-ups. A meta-analysis of homogenous studies and outcomes was performed, otherwise, descriptive statistics were presented.

Results

Sixteen studies (2278 hips) with FAIS were included, in which 1196 hips underwent HA and 1082 hips were treated nonoperatively. There were 8 ST studies, 4 MT studies, and 4 LT studies. A meta-analysis of 2 comparative studies found 32% (P = .002) less risk of progression of radiographic OA (any increase in grading) with HA compared with nonoperative management. In addition, there was a nonsignificant 23% (P = .35) decreased risk of conversion to THA/hip resurfacing with HA. For all studies, there was a progression of hip OA ranging from 0% to 37.1% for ST studies, 11.5% to 23% for MT studies, and 4.3% to 28% for LT studies.

Conclusion

Our systematic review demonstrated that studies of patients undergoing HA for FAIS demonstrated increased radiographic progression of hip OA over time. Although significantly limited by only 2 retrospective cohort studies, subgroup analysis comparing operative versus nonoperative management demonstrated a 32% reduction in the radiographic progression of OA (any increase in grading) at the LT follow-up. However, there were no significant differences in the risk of THA/hip resurfacing. Future long-term, high-level controlled studies are needed to help further understand this important clinical question.

Association Between Global Overcoverage and Long-term Survivorship, Chondrolabral Junction Breakdown, and Reduced Joint Space Width: Minimum 8-Year Follow-up

BACKGROUND

Although previous literature has established the association between femoroacetabular impingement and progressive hip osteoarthritis, there exists a paucity of studies investigating the effects of global acetabular overcoverage on chondral wear and long-term outcomes.

PURPOSE

To compare baseline joint space width (JSW), intraoperative findings, long-term total hip arthroplasty (THA)-free survivorship, patient-reported outcome measures (PROMs), pain levels, and patient satisfaction in patients who underwent hip arthroscopy with global overcoverage (GO) to a matched-control (MC) cohort.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In this retrospective analysis, the authors queried patients who underwent hip arthroscopy for acetabular labral tears secondary to femoroacetabular impingement. Patients with complete PROMs at a minimum 8-year follow-up, the presence of coxa profunda as indicated by an acetabular wall projecting medial to the ilioischial line, and a lateral center-edge angle >40° were matched 1:1 by sex, age, body mass index, Tönnis grade, and labral treatment to a MC cohort of patients who had normal acetabular coverage. Baseline radiographic and intraoperative findings were compared between cohorts. Collected outcomes include the modified Harris Hip Score, Nonarthritic Hip Score, Lower Extremity Functional Scale score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, 33-item International Hip Outcome Tool score, pain levels, patient satisfaction, and conversion to THA.

RESULTS

In total, 38 patients with GO were 1:1 matched to a MC cohort. The GO cohort had significantly decreased baseline JSW at 50° (P = .002) and greater chondrolabral junction breakdown (P = .037). The GO and MC cohorts achieved similar outcomes for all 6 PROMs, rates of conversion to THA, pain levels, and patient satisfaction. Kaplan-Meier survival analysis demonstrated that the patients experienced a similar overall 18-year THA-free survival rate (GO: 71.1% vs MC: 84.2%; P = .101). To isolate the long-term effects of GO on hip arthroscopy outcomes, 6- to 18-year THA-free survivorship was examined, revealing that the GO cohort (-13.1%) experienced a significantly greater decrease compared with the MC cohort (-5.3%) (P = .008).

CONCLUSION

Patients with GO had significantly lower baseline ipsilateral JSW at 50° and greater intraoperative severity of chondrolabral junction breakdown. Furthermore, the GO cohort experienced a significantly greater decrease in long-term THA-free survivorship 6 to 18 years after hip arthroscopy.

Femoroacetabular Impingement: Preoperative Evaluation and Postoperative Imaging

Femoroacetabular impingement (FAI) is a significant orthopaedic condition that primarily affects young active adults. It is characterized by abnormal contact between the femoral head and the acetabulum, leading to joint damage and osteoarthritis. This syndrome presents in three forms: pincer, cam, and mixed impingement, each with distinct morphological characteristics that can cause labral tears and cartilage damage. Over the last 20 years, the diagnosis and management of FAI has evolved considerably with advancements in imaging technologies and surgical techniques, especially hip arthroscopy.This article reviews the pathophysiology, diagnostic imaging criteria, surgical treatments, and postoperative outcomes of FAI, providing essential insights for radiologists and surgeons. The importance of early and accurate diagnosis through advanced imaging is emphasized to prevent the progression of FAI and to plan effective surgical interventions aimed at joint preservation. Challenges remain in the postoperative setting, where residual symptoms can require revision surgeries. Future directions in the management of FAI will likely focus on refining imaging protocols and surgical techniques to enhance the success rates of primary procedures and reduce the need for subsequent interventions.

Femoroacetabular Impingement: Preoperative Planning and Postoperative MR Imaging Evaluation

Imaging plays a critical role in the preoperative and postoperative evaluation of patients with femoroacetabular impingement. Non-contrast MR imaging and direct magnetic resonance arthrography of the hip are the modalities of choice for the preoperative assessment of chondrolabral lesions. The MRI protocol should include radial images for detailed analysis of the cam deformity and fast sequences covering the pelvis and knee for measurement of femoral torsion. In patients with postoperative pain, a comprehensive analysis of residual deformities and signs of osseous overcorrection should be performed as they can cause residual impingement or iatrogenic instability.

Editorial Commentary: Arthroscopic Hip Labral Preservation Combined With Bony Correction and Capsular Closure Results in Improved Patient Outcomes

Hip labral reconstruction aims to replace an irreparable or insufficient labrum with the goal of restoring the native function of the labrum and thus contribute to hip preservation. Multiple studies have reported success and improved outcomes with labral reconstruction, both in primary and revision settings. The function of the labrum includes providing additional soft-tissue coverage of the femoral head and contributing to regulation of fluid dynamics within the hip joint through the "suction seal." Labral tears and insufficiency alter hip joint biomechanics, which could result in hip microinstability and joint degeneration. Yet, although labral reconstruction is better than a labral-deficient state, labral reconstruction does not restore native hip biomechanics when compared with the native intact labrum. However, concomitant procedures to address bony morphology, hip capsule, cartilage, and adhesions in the revision setting frequently are performed at the time of labral reconstruction, making the true effect of labral reconstruction unknown. Therefore, the labrum should be considered as one of many variables when evaluating individuals with hip pain, and surgeons who perform hip arthroscopy should ensure that appropriate patient selection and additional pathology are adequately addressed in the primary and revision settings.

Advances in Molecular Research on Hip Joint Impingement-A Vascular Perspective

With the rise in longevity within the population, medicine continues to encounter fresh hurdles necessitating prompt actions, among which are those associated with hip joint aging. Age-related arthropathies encompass damage to bones' articulating extremities and their supporting structures, such as articular cartilage, and alterations in the quantity and quality of synovial fluid. This study aims to summarize the biomolecular methods of hip joint evaluation focused on its vascularization, using data correlated with biomolecular research on other joints and tissues, in order to reach an objective opinion of the study prospects in this field. Following a retrospective study on most modern biomolecular research methods on the synovium, the capsule, and the articular cartilage of the hip joint, we have hereby concretized certain future research directions in this field that will improve the qualitative and morphofunctional management of the hip joint at an advanced age, even within population categories at risk of developing various degenerative joint pathologies.