Predictors of Hip Pain and Function in Femoroacetabular Impingement: A Prospective Cohort Analysis

Association Between Symptoms of Anxiety and Depression, Hip Pathology, and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

In patients with femoroacetabular impingement (FAI), mental health has been implicated in both symptom severity and postoperative outcomes. However, there are limited data regarding the independent influences of baseline mental health and hip pathology on patient-reported outcomes over time after hip arthroscopy.

PURPOSE

To evaluate the association between mental health and structural hip pathology with pain, hip function, and quality of life (QOL).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patient records from a single surgeon's hip outcomes registry were retrospectively reviewed. Mental health was evaluated using the Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores. Pain was evaluated with the Single Assessment Numeric Evaluation score for Activities of Daily Living (SANE-ADL), while hip-related QOL was evaluated with the 12-item International Hip Outcome Tool (iHOT-12). Hip function was assessed with the Hip Outcome Score (HOS) Sport-Specific (SS) and ADL subscales. Separate mixed models were used to predict pain, QOL, and hip function, including hip pathology measures (size of labral tear, grade of chondral damage, preoperative alpha angle), anxiety, depression, and time as fixed effects and individuals as a random effect.

RESULTS

A total of 312 patients were included in this study. The preoperative alpha angle, degree of intraoperative cartilage damage, and size of the labral tear were not associated with pain or QOL (P > .05 for all). However, higher levels of anxiety and depression were significantly associated with lower SANE-ADL scores (estimate ± SE) (anxiety: -0.59 ± 0.07, P < .0001; depression: -0.64 ± 0.08, P < .0001), iHOT-12 scores (anxiety: -0.72 ± 0.07, P < .0001; depression: -0.72 ± 0.08, P < .0001), HOS-SS scores (anxiety: -0.68 ± 0.09, P < .0001; depression: -0.57 ± 0.10, P < .0001), and HOS-ADL scores (anxiety: -0.43 ± 0.05, P < .0001; depression: -0.43 ± 0.06, P < .0001).

CONCLUSION

Patients had similar improvements in pain scores, QOL, and hip function after hip arthroscopy for FAI irrespective of their degree of hip pathology. Additionally, preoperative symptoms of anxiety and depression symptoms were associated with greater pain, decreased QOL, and worse hip function both pre- and postoperatively, independent of the degree of hip pathology. This suggests that efforts to directly address symptoms of anxiety and depression may improve outcomes after hip arthroscopy.

Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis

BACKGROUND

Little is known about the effect of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation.

PURPOSE

To (1) characterize the natural history of FAIS and (2) understand the effect of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of 10 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between 2010 and 2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopic surgeon. Inclusion criteria were FAIS, bilateral radiographic findings of femoroacetabular impingement, primary unilateral hip arthroscopy (labral repair, femoroplasty, or capsular closure), and minimum 10-year follow-up. The preoperative and minimum 10-year postoperative radiographs of patients were evaluated at each time point. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by 2 independent reviewers. Subgroup analyses were performed.

RESULTS

A total of 200 hips from 100 patients were evaluated at a mean follow-up of 12.0 years. Preoperatively, 98% and 99% of operative and nonoperative hips were evaluated as Tönnis grades 0 and 1, respectively; 5% of nonoperative hips had worse Tönnis grades than operative hips. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared with 28% (28/100) among operative hips. At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time. Modern hip arthroscopy was associated with a relative risk reduction of 42% in osteoarthritis progression. Impingement with borderline dysplasia, age, preoperative Tönnis grade, and alpha angle >65° were key risk factors in the radiographic progression of osteoarthritis.

CONCLUSION

Although the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history may be favorably altered for 25% of patients whose Tönnis grade was better after undergoing arthroscopic correction. Modern hip arthroscopy indications and techniques represent a valid joint-preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Arthroscopy for mixed patterns of impingement and instability were the fastest to degenerate.

Pain Catastrophizing, Kinesiophobia, Stress, Depression, and Poor Resiliency Are Associated With Pain and Dysfunction in the Hip Preservation Population

Background

Psychiatric disorders are known to have a negative impact on outcomes attained from hip-preservation surgery. Psychosocial traits such as resiliency and pain avoidance likely also affect treatment outcomes, however these characteristics are less easily identified, and data is lacking supporting their presence and impact on related outcomes within the hip preservation population. We therefore evaluated hip preservation patients for a variety of maladaptive psychosocial traits and assessed patient-reported outcomes (PROs) in order to ascertain which specific traits were most associated with hip pain and dysfunction.

Methods

62 subjects aged 15-49 years presenting for evaluation of a nonarthritic hip condition completed psychosocial questionnaires and patient reported outcome measures via electronic survey as listed in table one. Participants were tested again eight weeks later to evaluate the relationship between changes in physical function, pain, and mental health behaviors. Pearson correlation coefficients assessed association between hip PROs and psychosocial tests and analyses were corrected for multiple comparisons.

Results

Pain Catastrophizing (PCS), Kinesiophobia (TSK), Stress, and PROMIS-Global Mental Health (GMH) scores correlated with poor physical function and high pain scores at zero and eight weeks. Low resiliency (BRS) and depression were also associated with elevated pain on PRO tests as well as HOOS-Physical Function. There was a moderately strong correlation between improvement in PROMIS-Physical Function (PF) from zero to eight weeks and subjects initial scores for kinesiophobia, anxiety, and stress (r= -0.45, -0.41, -0.44, all p<0.05).

Conclusion

PCS, TSK, Stress, Depression, and low BRS are associated with pain and disability in hip preservation subjects. Elevated TSK, Anxiety and Stress may be predictors of failure to improve with nonoperative treatment. These psychosocial characteristics should be investigated further as predictors of clinical outcomes in the hip preservation population. Level of Evidence: II.

Osteoarthritis of the hip: is radiography still needed?

Diagnosis of hip osteoarthritis (OA) is based on clinical arguments, and medical imaging is obtained to confirm the diagnosis and rule out other possible sources of pain. Conventional radiographs are recommended as the first line imaging modality to investigate chronic hip pain. They should be obtained in a rigorous technique that includes an antero-posterior (AP) radiograph of the pelvis. The choice of the appropriate lateral view depends on the clinical indication, Lequesne's false profile being valuable in the assessment of OA. Magnetic resonance imaging (MRI) is more sensitive to detect joint effusion/synovitis, cartilage, labral, and bone marrow lesions. However, structural joint changes are frequent in asymptomatic population and neither radiographs nor MRI have shown a good correlation with pain and functional impairment. MRI seems to be more suitable than radiographs as a biomarker for clinical trials addressing early OA. The absence of a validated MR biomarker of early OA, together with issues related to machine availability and MRI protocol repeatability, prevent the widespread use of MRI in clinical trials.

Association of Changes in Hip and Knee Kinematics During a Single-Leg Squat With Changes in Patient-Reported Outcomes at 6 Months and 1 Year After Hip Arthroscopy

BACKGROUND

Previous studies have demonstrated alterations in squat kinematics in patients with femoroacetabular impingement syndrome (FAIS). Little is known about the effects of arthroscopic hip surgery on biomechanics during a single-leg squat (SLS) in these patients.

PURPOSE/HYPOTHESIS

The purpose of this study was to determine if (1) lower extremity dynamic range of motion (ROM) during an SLS task improves after hip arthroscopy for FAIS and (2) correlations exist between changes in patient-reported outcomes (PROs) and changes in lower extremity dynamic ROM during an SLS after hip arthroscopy for FAIS. It was hypothesized that dynamic hip ROM would improve after hip arthroscopy and that hip dynamic ROM would be associated with changes in PRO scores at both 6 months and 1 year.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Patients with FAIS performed 3 SLSs that were analyzed using a 20-camera motion capture system. Dynamic ROMs were calculated in 3 planes for the hip, knee, ankle, and pelvic segments. Squat depth was calculated as the change in vertical center of mass during the squat cycle. PROs including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports (HOS-Sports), International Hip Outcome Tool-12, and visual analog scale for pain scores were collected preoperatively and at the time of postoperative testing. Paired-samples t tests were used to compare kinematic variables pre- and postoperatively. Correlations were used to compare changes in PROs with changes in kinematics. All statistical analysis was performed using SPSS Version 26.

RESULTS

Fifteen patients were tested preoperatively and at a mean of 9 months postoperatively. All PRO measures improved postoperatively at 6 months and 1 year. Squat depth and sagittal plane hip and knee dynamic ROMs were significantly improved postoperatively. Positive correlations existed between changes in (1) hip ROM with the 6-month HOS-ADL score (r = 0.665) and (2) knee ROM with the 6 month (r = 0.590) and 1-year (r = 0.565) HOS-Sports scores.

CONCLUSION

Dynamic sagittal plane hip and knee ROMs improve after hip arthroscopy for FAIS. These improvements demonstrate strong correlations with improvements in some but not all postoperative PROs.

CLINICAL RELEVANCE

The current study sought to better understand the role of dynamic movement in the diagnosis and treatment of FAIS. These findings indicate that dynamic ROM and squat depth can, similarly to PROs, serve as biomarkers for patient function both before and after hip arthroscopic surgery.

Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis

Background

Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources.

Purpose

To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS.

Study Design

Cohort study; Level of evidence, 3.

Methods

Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated.

Results

Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient.

Conclusion

Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.

Which hip morphology measures and patient factors are associated with age of onset and symptom severity in femoroacetabular impingement syndrome?

BACKGROUND

Bony morphology is central to the pathomechanism of femoroacetabular impingement syndrome (FAIS), however isolated radiographic measures poorly predict symptom onset and severity. More comprehensive morphology measurement considered together with patient factors may better predict symptom presentation. This study aimed to determine the morphological parameter(s) and patient factor(s) associated with symptom age of onset and severity in FAIS.

METHODS

99 participants (age 32.9 ± 10.5 years; body mass index (BMI 24.3 ± 3.1 kg/m²; 42% females) diagnosed with FAIS received standardised plain radiographs and magnetic resonance scans. Alpha angle in four radial planes (superior to anterior), acetabular version (AV), femoral torsion, lateral centre-edge, anterior centre-edge (ACEA) and femoral neck-shaft angles were measured. Age of symptom onset (age at presentation minus duration of symptoms), international Hip Outcome Tool-33 (iHOT-33) and modified UCLA activity scores were recorded. Backward stepwise regression assessed morphological parameters and patient factors (age, sex, BMI, symptom duration, annual income, private/public healthcare system accessed) to determine variables independently associated with onset age and iHOT-33 score.

RESULTS

Earlier symptom onset was associated with larger superoanterior alpha angle (p = 0.007), smaller AV (p = 0.023), lower BMI (p = 0.010) and public healthcare system access (p = 0.041) (r² = 0.320). Worse iHOT-33 score was associated with smaller ACEA (p = 0.034), female sex (p = 0.040), worse modified UCLA activity score (p = 0.010) and public healthcare system access (p < 0.001) (r² = 0.340).

CONCLUSIONS

Age of symptom onset was chiefly predicted by femoral and acetabular bony morphology measures, whereas symptom severity predominantly by patient factors. Factors measured explained a small amount of variance in the data; additional unmeasured factors may be more influential.

Moderators, Mediators, and Prognostic Indicators of Treatment With Hip Arthroscopy or Physical Therapy for Femoroacetabular Impingement Syndrome: Secondary Analyses From the Australian FASHIoN Trial

BACKGROUND

Although randomized controlled trials comparing hip arthroscopy with physical therapy for the treatment of femoroacetabular impingement (FAI) syndrome have emerged, no studies have investigated potential moderators or mediators of change in hip-related quality of life.

PURPOSE

To explore potential moderators, mediators, and prognostic indicators of the effect of hip arthroscopy and physical therapy on change in 33-item international Hip Outcome Tool (iHOT-33) score for FAI syndrome.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Overall, 99 participants were recruited from the clinics of orthopaedic surgeons and randomly allocated to treatment with hip arthroscopy or physical therapy. Change in iHOT-33 score from baseline to 12 months was the dependent outcome for analyses of moderators, mediators, and prognostic indicators. Variables investigated as potential moderators/prognostic indicators were demographic variables, symptom duration, alpha angle, lateral center-edge angle (LCEA), Hip Osteoarthritis MRI Scoring System (HOAMS) for selected magnetic resonance imaging (MRI) features, and delayed gadolinium-enhanced MRI of cartilage (dGEMRIC) score. Potential mediators investigated were change in chosen bony morphology measures, HOAMS, and dGEMRIC score from baseline to 12 months. For hip arthroscopy, intraoperative procedures performed (femoral ostectomy ± acetabular ostectomy ± labral repair ± ligamentum teres debridement) and quality of surgery graded by a blinded surgical review panel were investigated for potential association with iHOT-33 change. For physical therapy, fidelity to the physical therapy program was investigated for potential association with iHOT-33 change.

RESULTS

A total of 81 participants were included in the final moderator/prognostic indicator analysis and 85 participants in the final mediator analysis after exclusion of those with missing data. No significant moderators or mediators of change in iHOT-33 score from baseline to 12 months were identified. Patients with smaller baseline LCEA (β = -0.82; P = .034), access to private health care (β = 12.91; P = .013), and worse baseline iHOT-33 score (β = -0.48; P < .001) had greater iHOT-33 improvement from baseline to 12 months, irrespective of treatment allocation, and thus were prognostic indicators of treatment response. Unsatisfactory treatment fidelity was associated with worse treatment response (β = -24.27; P = .013) for physical therapy. The quality of surgery and procedures performed were not associated with iHOT-33 change for hip arthroscopy (P = .460-.665 and P = .096-.824, respectively).

CONCLUSION

No moderators or mediators of change in hip-related quality of life were identified for treatment of FAI syndrome with hip arthroscopy or physical therapy in these exploratory analyses. Patients who accessed the Australian private health care system, had smaller LCEAs, and had worse baseline iHOT-33 scores, experienced greater iHOT-33 improvement, irrespective of treatment allocation.

Outcomes Among Athletes Versus Nonathletes After Arthroscopic Management of Femoroacetabular Impingement

This study synthesizes and reports patient-reported outcomes (PROs) among athletes vs nonathletes after hip arthroscopy for femoroacetabular impingement. A systematic review was performed in November 2020 with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) process. We included studies that reported PROs for athletes vs nonathletes. We excluded articles that did not contain full text, that were not in English, and that included level IV evidence. Four studies reporting on a total of 294 athletes and 230 nonathletes were included. Of these studies, 3 found superior outcomes among athletes, and 1 found that athletes recovered faster, but nonathletes had equivalent outcomes at later follow-up. Athletes and nonathletes showed significant improvements in PROs; however, athletes showed a trend toward superior PROs. Thus, pre-operative athletic activity is associated with favorable outcomes after hip arthroscopy. [Orthopedics. 2022;45(6):e288-e294.].

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

BACKGROUND

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

HYPOTHESIS

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

STUDY DESIGN

Cross-sectional study.

LEVEL OF EVIDENCE

Level 4.

METHODS

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

RESULTS

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

CONCLUSION

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

CLINICAL RELEVANCE

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

Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost-Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5-Year Analysis

PURPOSE

To assess the clinical utility of preoperative magnetic resonance imaging (MRI) and quantify the delay in surgical care for patients aged ≤40 years undergoing primary hip arthroscopy with history, physical examination, and radiographs concordant with femoroacetabular impingement syndrome (FAIS).

METHODS

From August 2015 to December 2020, 1,786 consecutive patients were reviewed from the practice of 1 fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of conservative management, or concomitant periacetabular osteotomy. After nonoperative treatment options were exhausted and a surgical plan was established, patients were stratified by those who presented with versus without MRI. Those without existing MRI received one, and any deviations from the surgical plan were noted. All preoperative MRIs were compared with office evaluation and intraoperative findings to assess agreement. Demographic data, Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, and time from office to MRI or arthroscopy were recorded.

RESULTS

Of the patients indicated by history, physical examination, and radiographs alone (70% female, body mass index 24.8 kg/m², age 25.9 years), 198 patients presented without MRI and 934 with MRI. None of the 198 had surgical plans altered after MRI. Patients in both groups had MRI findings demonstrating anterosuperior labral tears that were visualized and repaired intraoperatively. Mean time from office to arthroscopy for patients without MRI versus those with was 107.0 ± 67 and 85.0 ± 53 days, respectively (P < .001). Time to MRI was 22.8 days. No difference between groups was observed among the 85% of patients who surpassed the HOOS-Pain minimal clinically important difference (MCID).

CONCLUSION

Once indicated for surgery based on history, physical examination, and radiographs, preoperative MRI did not alter the surgical plan for patients aged ≤40 years with FAIS undergoing primary hip arthroscopy. Moreover, preoperative MRI delayed time to arthroscopy. The necessity of routine preoperative MRI in the young primary FAIS population should be challenged.

Is Internal Rotation Measurement of the Hip Useful for Ruling in Cam or Pincer Morphology in Asymptomatic Males? A Diagnostic Accuracy Study

BACKGROUND

Cam and pincer morphologies are associated with limited internal rotation. However, the routine clinical examination for hip rotation has limited reliability. A more standardized method of measuring hip rotation might increase test-retest and interobserver reliability and might be useful as a screening test to detect different hip morphologies without the need for imaging. We developed an examination chair to standardize the measurement of internal hip rotation, which improved interobserver reliability. However, the diagnostic test accuracy for this test is unknown.

QUESTION/PURPOSE

Is a standardized method of determining internal hip rotation using an examination chair useful in detecting cam and pincer morphology with MRI as a reference standard?

METHODS

A diagnostic test accuracy study was conducted in a sample of asymptomatic males. Using an examination chair with a standardized seated position, internal rotation was measured in 1080 men aged 18 to 21 years who had been conscripted for the Swiss army. The chair prevents compensatory movement by stabilizing the pelvis and the thighs with belts. The force to produce the internal rotation was standardized with a pulley system. Previous results showed that the measurements with the examination chair are similar to clinical assessment but with higher interobserver agreement. A random sample of 430 asymptomatic males was invited to undergo hip MRI. Of those, 244 White European males responded to the invitation and had a mean age of 20 ± 0.7 years and a mean internal rotation of the hip of 33° ± 8.5°. Using MRI as the reference standard, 69% (169 of 244) had a normal hip, 24% (59 of 244) a definite cam morphology (Grades 2 and 3), 3% (8 of 244) an increased acetabular depth, and 3% (8 of 244) a combination of both. One experienced radiologist graded cam morphology as follows: 0 = normal, 1 = mild, 2 = moderate, and 3 = severe. Pincer morphology was defined by increased acetabular depth (≤ 3 mm distance between the center of the femoral neck and the line connecting the anterior and posterior acetabular rims). The intraobserver agreement was substantial (weighted κ of 0.65). A receiver operating characteristic (ROC) curve was fitted, and sensitivity, specificity, and likelihood ratios were estimated for different internal rotation cutoffs.

RESULTS

For cam morphology, the area under the ROC curve was 0.75 (95% CI 0.67 to 0.82). Internal hip rotation of less than 20° yielded a positive likelihood ratio of 9.57 (sensitivity 0.13, specificity 0.99), and a value of 40° or more resulted in a negative likelihood ratio of 0.36 (sensitivity 0.93, specificity 0.20). The area under the curve for detecting the combination of cam and pincer morphologies was 0.87 (95% CI 0.74 to 1.0). A cutoff of 20° yielded a positive likelihood ratio of 9.03 (sensitivity 0.33, specificity 0.96).

CONCLUSION

This examination chair showed moderate-to-good diagnostic value to rule in hip cam morphology in White European males. However, at the extremes of the 95% confidence intervals, diagnostic performance would be poor. Nonetheless, we believe this test can contribute to identifying cam morphologies, and we hope that future, larger studies-ideally in more diverse patient populations-will seek to validate this to arrive at more precise estimates of the diagnostic performance of this test.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Male Gender and Competitive Athlete Status Are Associated With Better Outcomes Following Hip Arthroscopy In Patients With Global Acetabular Retroversion

Purpose

To evaluate outcomes of hip arthroscopy in patients with global acetabular retroversion and to identify correlations between sex, radiographic measurements, athlete status, and return to play with patient-reported outcomes (PROs).

Methods

Retrospective study of patients with global acetabular retroversion who underwent arthroscopic femoroacetabular impingement (FAI) surgery was performed. Global acetabular retroversion was defined by 3 criteria: the crossover sign, ischial spine sign, and posterior wall sign on an anteroposterior (AP) pelvic radiograph. Radiographs were used to measure lateral center edge angle, alpha angle, and anterior and posterior wall indices. Femoral version was measured with 3-dimensional computed tomography. Demographics included age, gender, athlete status, return to play, and reoperation. PROs included modified Harris Hip Score, Hip Outcome Score (HOS), Hip Disability and Osteoarthritis Outcome Score, visual analog scale (VAS), and Veterans RAND-12. Spearman correlation determined correlation with perioperative PROs. Generalized estimating equation determined independent predictors. Significance was set at P = .05.

Results

From 2013 to 2019, 149 patients (65.0% female) with 160 hips with FAI and global acetabular retroversion underwent hip arthroscopy. Follow-up averaged 29.6 months. All PROs demonstrated significant improvement with the exception of the Veterans RAND-12 Mental. Female patients scored significantly lower on most postoperative PROs and had greater VAS scores (P = .0002-0.0402). A greater proportion of male subjects met the minimum clinically important difference for the modified Harris Hip Score (88.00% vs 78.79%) Low femoral version correlated with greater HOS ADL, HOS Sport, and Hip Disability and Osteoarthritis Outcome Score Sport scores (P = .0077-0.0177). Athletes reported lower preoperative VAS scores, and higher perioperative scores in multiple PROs (P = .0004-0.0486). Nine hips (5.63%) underwent reoperation.

Conclusions

Patients with global acetabular retroversion and FAI undergoing hip arthroscopy report good outcomes at short-term follow-up. Male subjects and athletes had superior outcomes compared to female subjects and nonathletes. Radiographic measurements did not correlate with outcomes with exception of low femoral version. Athletes reported lower preoperative pain scores and greater postoperative PROs than nonathletes.

Level of Evidence

Level IV, therapeutic case series.

Factors Associated With Pain and Function Before Medial Patellofemoral Ligament Reconstruction

Background:

Medial patellofemoral ligament (MPFL) reconstruction is performed to treat recurrent patellar instability. Measurement of joint pain and function at the time of surgery has been demonstrated to be a predictor of the final outcomes in many surgical procedures.

Purpose/Hypothesis:

The purpose of this study was to evaluate the relationship between baseline patient characteristics, mental health, and intraoperative findings and patient-reported knee pain and function at the time of MPFL reconstruction. We hypothesized that patient characteristics and associated pathology would be associated with the degree of pain and dysfunction.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

Included were skeletally mature patients who underwent unilateral open MPFL reconstruction between 2015 and 2020 at a single institution. Baseline descriptive information was collected, and the following outcome measures were administered preoperatively: the Veterans RAND 12-Item Health Survey Mental Component Score (VR-12 MCS) and the Knee injury and Osteoarthritis Outcome Score (KOOS) Pain, Physical Function Short Form (PS), and Quality of Life (QoL) subscales. Intraoperative findings were collected in a standardized format. Patient characteristics, preoperative variables, intraoperative findings, and VR-12 MCS were used as risk factors, and multivariate analysis was conducted to assess for relationships with the KOOS subscale scores.

Results:

In total, 201 patients with patella dislocations were included in this analysis. Intraoperatively, 122 patients (60.7%) had either normal cartilage or grade 1 or 2 cartilage injury, 79 patients (39.3%) had grade 3 or 4 cartilage injury, 35 patients (17.4%) had a loose body, and 3 patients (1.49%) had evidence of synovitis. Younger age (P = .012), male sex (P < .001), never having smoked (P = .029), and lower baseline VR-MCS (P < .001) were significantly associated with higher baseline KOOS Pain scores. Older age (P = .035), female sex (P = .003), higher body mass index (P = .005), and lower baseline VR-12 MCS (P < .001) were significantly associated with higher baseline KOOS PS scores. Younger age (P = .003), male sex (P < .001), lower baseline VR-12 MCS (P < .001), and no dysplasia (P = .023) were significantly associated with higher baseline KOOS QoL scores.

Conclusion:

Patient age, sex, and baseline VR-12 MCS were associated with all 3 baseline KOOS subscale scores, whereas intraoperative findings outside of trochlear dysplasia were not associated with any of the KOOS subscale scores.

Automated Text-Messaging After Hip Arthroscopy: A Randomized-Controlled Trial of "Post-Op Buddy"

PURPOSE

To assess an automated text-messaging system for patients after hip arthroscopy and its impact at 90 days on the Hip Disability Osteoarthritis Outcome Score Physical Function Short form (HOOS-PS, HOOS-Pain), compliance with rehabilitation guidelines, and patient satisfaction.

METHODS

One hundred twenty-one participants (average age 29 ± 8.7 years, 52% female) undergoing hip arthroscopy at 2 academic institutions were prospectively enrolled and randomized to receive (1) standard perioperative communication or (2) additional automated mobile phone text messages. Inclusion criteria included ability to communicate in written English and access to a mobile phone with text-messaging capability. Patients undergoing revision surgery or simultaneous femoral or acetabular osteotomy were excluded. HOOS-PS and HOOS-Pain were collected preoperatively, and after surgery an automated mobile phone robot sent participants in the therapeutic arm intermittent text messages for 90 days. At 90 days all participants again completed HOOS-PS, HOOS-Pain, and additional survey questions on satisfaction with their experience (10-point scale), communication from the surgical team (10-point scale) and adherence to physical therapy exercises, weight-bearing guidelines, and brace use, The primary outcome assessed was a statistically significant change in HOOS-PS and HOOS-Pain; secondary outcomes included change in satisfaction, communication, and adherence to physical therapy exercises, weightbearing guidelines, or brace use. Wilcoxon rank sum was used to compare HOOS-PS and HOOS-Pain scores at 0 and 90 days. Demographic characteristics and survey variables were compared using Students t test for continuous variables and χ² or Fisher exact test for categorical variables as appropriate.

RESULTS

There were statistically significant and clinically relevant improvements in HOOS-PS and HOOS-Pain in both groups (P < .05). Subjective feedback was strongly positive, with 96% of text message participants reporting they would choose automated messages if it was offered to them again in the future.

CONCLUSIONS

Ninety days of automated text messaging after hip arthroscopy failed to show a significant difference in HOOS-PS (P = .09), HOOS-Pain (P = .13), patient-reported compliance with postoperative guidelines, or satisfaction with support and communication from the surgical team.

LEVEL OF EVIDENCE

I, randomized control trial (RCT).

Effect of Cigarette Smoking on Outcomes in Patients Undergoing Primary Hip Arthroscopy and Labral Reconstruction: A Propensity-Matched Controlled Study With Minimum 2-Year Follow-up

Background:

There is a paucity of literature evaluating the effect of cigarette smoking on outcomes in patients undergoing hip arthroscopy and labral reconstruction.

Purpose:

(1) To report minimum 2-year patient-reported outcome (PRO) scores for patients who smoke cigarettes and underwent primary hip arthroscopic labral reconstruction and (2) to compare these results with those of a propensity-matched control group of patients who have never smoked.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were collected for all patients who underwent primary hip arthroscopy for labral reconstruction between January 2011 and January 2019. Patients were eligible for the study if they indicated that they smoked cigarettes within 1 month of surgery and had minimum 2-year postoperative outcome scores for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain. The percentage of patients achieving the minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) was recorded. Rates of revision surgery were also documented. These patients were then propensity matched in a 1:3 ratio to patients who had never smoked (controls) for comparison.

Results:

A total of 20 patients (20 hips) were included with a mean follow-up of 39.9 ± 13.0 months and mean age of 41.4 ± 10.4 years. These patients demonstrated significant improvement from preoperatively to the minimum 2-year follow-up for mHHS, NAHS, and VAS (P < .05). They also achieved MCID for mHHS and VAS at acceptable rates, 70% for both. When outcomes were compared with those of 60 control patients (60 hips), patients who smoke demonstrated lower preoperative PRO scores but similar minimum 2-year postoperative PRO scores for mHHS and NAHS. Patients who smoke demonstrated lower rates of achieving PASS for mHHS (55% vs 75%) and NAHS (40% vs 61.7%) compared with controls; however, these findings were not statistically significant. Rates of secondary surgery were statistically significantly higher in the smoking group compared with controls (25% vs 5%; P = .031). Survivorship for the smoking patients was 80% and 98.3% for the control group. At the two-year mark survivorship was 90% for the smoking group and 100% for the control group (P = .06)

Conclusion:

While smokers can still derive significant improvement from hip arthroscopy, their ultimate functional outcome and rate of secondary surgeries are inferior to those of nonsmokers. As smoking is a significant and modifiable risk factor, we should continue to counsel smokers on smoking cessation prior to and after surgery

Are cam morphology size and location associated with self‐reported burden in football players with FAI syndrome?

Cam morphology size and location might affect the severity of reported burden in people with femoroacetabular impingement (FAI) syndrome. We investigated the relationship between cam morphology size (i.e., alpha angle) and self‐reported hip/groin burden (i.e., scores for the International Hip Outcome Tool‐33 (iHOT‐33) and Copenhagen Hip and Groin Outcome Score (HAGOS)), examined separately for the anteroposterior pelvis (AP) and Dunn 45° radiographs in football players with FAI syndrome. In total, 118 (12 women) subelite football (soccer or Australian football) players with FAI syndrome with cam morphology (alpha angle ≥60°) participated. One blinded assessor quantified superior and anterosuperior cam morphology size by measuring alpha angles for the AP and Dunn 45° radiographs, respectively. Linear regression models investigated relationships between alpha angle (continuous independent variable, separately measured for the AP and Dunn 45° radiographs) and iHOT‐33 and HAGOS scores (dependent variables). Larger anterosuperior cam morphology (seen on the Dunn 45° radiograph) was associated with lower (i.e., worse) scores for the iHOT‐Total, iHOT‐Symptoms, iHOT‐Job, and iHOT‐Social subscales (unadjusted estimate range −0.553 to −0.319 [95% confidence interval −0.900 to −0.037], p = 0.002 to 0.027), but not the iHOT‐Sport (p = 0.459) nor any HAGOS scores (p = 0.110 to 0.802). Superior cam morphology size (measured using the AP radiograph) was not associated with any iHOT‐33 or HAGOS scores (p = 0.085 to 0.975). Larger anterosuperior cam morphology may be more relevant to pain and symptoms in football players with FAI syndrome than superior cam morphology, warranting investigation of its effects on reported burden and hip disease over time.

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure

OBJECTIVE

To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs.

DESIGN

Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders.

RESULTS

A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654).

CONCLUSION

Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic study.

One Bony Morphology, Two Pathologic Entities: Sex-Based Differences in Patients With Borderline Hip Dysplasia Undergoing Hip Arthroscopy

BACKGROUND

Sex-based differences have been largely uncharacterized for patients with borderline hip dysplasia (BHD) undergoing hip arthroscopy.

PURPOSE

To evaluate for sex-based differences in clinical and pathologic characteristics as well as surgical outcomes in patients with BHD undergoing hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2011 and December 2018, data were prospectively collected on all patients with BHD undergoing primary hip arthroscopy. Patients were included if they had preoperative and minimum 2-year postoperative scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain. Patients with previous ipsilateral hip conditions or surgery, Tönnis grade >1, lateral center-edge angle <18° or >25°, or workers' compensation status were excluded. Patients were then divided by sex and propensity score matched in a 1:1 ratio for body mass index, age, and Tönnis grade. The rates of patients who achieved the minimal clinically important difference were recorded for the mHHS and NAHS. The rates of achieving the patient acceptable symptomatic state for the mHHS were calculated.

RESULTS

A total of 344 hips met the inclusion criteria, and 317 hips (92%) had adequate follow-up. Propensity score matching created cohorts of 109 male and 109 female patients. Male patients had significantly higher preoperative average alpha angles (69.79° vs 58.17°, P < .001), more often requiring a femoroplasty (97.2% vs 83.5%, P < .001), and had higher rates of complex labral tearing (50.5% vs 33.0%, P < .001). Male patients also had higher rates of grade 3 and 4 acetabular labral articular disruption (62.4% vs 19.3%, P < .001) and higher rates of grade 3 and 4 acetabular cartilage injury (59.6% vs 20.2%, P < .001) requiring a microfracture more frequently (32.1% vs 7.3%, P < .001). Female patients more typically had painful internal snapping requiring iliopsoas fractional lengthening (60.6% vs 32.1%, P < .001). Female patients also underwent capsular plication more regularly to address hip instability (79.8% vs 45.9%, P < .001). Male and female patients showed significant improvements in all outcome scores after surgery (P < .001). Female patients achieved the minimal clinically important difference for the NAHS at higher rates (85.3% vs 71.6%, P = .020).

CONCLUSION

Female and male patients with BHD who underwent hip arthroscopy achieved favorable outcomes but had notably dissimilar pathology. Hence, although they share similar acetabular bony morphology, male and female patients with BHD may represent 2 very different pathologic entities.

Effectiveness of a Web-Based Electronic Prospective Data Collection Tool for Surgical Data in Shoulder Arthroplasty

Background

The purpose of this study was to demonstrate the validity and efficiency of the Outcomes Management and Evaluation (OME) system, a prospectively designed electronic data collection tool, for collecting comprehensive and standardized surgical data in shoulder arthroplasty.

Methods

Surgical data from the first 100 cases of shoulder arthroplasty that were collected into the OME database were analyzed. Surgeons completed a traditional narrative operative note and also an OME case report using an encrypted smartphone. A blinded reviewer extracted data from the operative notes and implant logs in the electronic medical records (EMR) by manual chart review. OME and EMR data were compared with regard to data counts and agreement between 39 variables related to preoperative pathology, including rotator cuff status and glenoid wear, and surgical procedures. Data counts were assessed using both raw percentages and with McNemar's test (with continuity correction). Agreement of nominal variables was analyzed using Cohen's unweighted kappa (κ) and of ordinal variables using the linearly weighted Cohen's test. Efficiency was assessed by calculating the median time needed to complete OME.

Results

Compared to the EMR, the OME database had significantly higher data counts for 56% (22 of 39) of the variables assessed. A high level of proportional and statistical agreement was demonstrated between the data in the two datasets. 10 of 39 variables had 100% agreement but could not be statistically compared because both datasets had the same single response under those variables. Among the 29 variables that were compared, 79% (23 of 29) of variables had >80% raw proportional agreement, and 69% (20 of 29) of variables showed at least substantial agreement (κ > 0.6). The median time for completing OME surgery data entry was 92 seconds (IQR 70 - 126).

Conclusion

The prospectively designed, electronic data entry system (OME) is an efficient and valid tool for collecting comprehensive and standardized surgical data on shoulder arthroplasty.

Level of Evidence

Level IV.

Effect of Baseline Mental Health on 1-Year Outcomes After Hip Arthroscopy: A Prospective Cohort Study

Background:

Patient factors, including mental health, sex, and smoking, have been found to be more predictive of preoperative hip pain and function than intra-articular findings during hip arthroscopy for femoroacetabular impingement (FAI); however, little is known about how these factors may influence patients’ postoperative outcomes.

Hypothesis:

We hypothesized that lower patient-reported mental health scores would be significant risk factors for worse patient-reported outcomes (PROs) 1 year after arthroscopic hip surgery for FAI and that baseline intra-articular pathology would fail to demonstrate an association with outcomes 1 year after FAI surgery.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A prospective cohort of patients undergoing hip arthroscopy for FAI were electronically enrolled. Baseline and 1-year follow-up PROs were collected, including Hip disability and Osteoarthritis Outcome Score for pain (HOOS-Pain), HOOS–Physical Function Short Form (HOOS-PS), and Veterans RAND 12-Item Health Survey–Mental Component Score (VR-12 MCS). Intra-articular operative findings and treatment were documented at the time of surgery. Proportional odds logistic regression models were built for 1-year outcomes (HOOS-Pain, HOOS-PS, and VR-12 MCS). Risk factors included patient characteristics and intraoperative anatomic and pathologic findings.

Results:

Overall, 494 patients underwent hip arthroscopy for FAI, and 385 (78%) were evaluated at 1 year with at least 1 PRO. The median patient age was 33 years, mean body mass index was 25.5 kg/m², and 72% were female. Multivariable analysis demonstrated that better baseline HOOS-Pain, HOOS-PS, and VR-12 MCS were significantly associated with improvement in the 1-year scores for each PRO. Higher VR-12 MCS was significantly associated with better 1-year HOOS-Pain and HOOS-PS, while current and former smokers had worse 1-year outcomes than those who never smoked. In ranking each variable’s relative importance, baseline HOOS-Pain and HOOS-PS and baseline VR-12 MCS were identified as the strongest predictors of 1-year HOOS-Pain and HOOS-PS in our multivariable model.

Conclusion:

During hip arthroscopy for FAI, patient factors, including baseline hip pain and function, mental health, and smoking, were independently associated with 1-year PROs of hip pain and function, while intra-articular pathology such as the presence of labral tear and its treatment, tear size, tear location, and anchors placed were not independently associated.

Publication Trends and Hot Spots in Femoroacetabular Impingement Research: A 20-Year Bibliometric Analysis

BACKGROUND

Femoroacetabular impingement (FAI) has attracted increasing attention over the past few decades. We aim to evaluate FAI research and predict research hot spots quantitatively and qualitatively.

METHODS

The publications in FAI research between 2000 and 2019 were assimilated from the Web of Science Core Collection of Clarivate Analytics. The retrieved data were evaluated by the bibliometric method. Software CiteSpace 5.7.R1, VOSviewer 1.6.15, and the Online Analysis Platform of Literature Metrology (http://bibliometric.com/) were used to analyze and identify the hot spots and trends in this field.

RESULTS

A total of 2471 originals articles that fulfilled the study requirements were obtained. The number of manuscripts on FAI has experienced rapid growth, especially after 2009. The United States of America was the leading country for publication and to the collaboration network. FAI, osteoarthritis, hip arthroscopy, labral reconstruction, pathomorphology, outcome, rehabilitation, and joint cartilage are some of the high-frequency keywords in co-occurrence cluster analysis and cocited reference cluster analysis. Burst detection analysis of top keywords revealed that outcomes, instability, labral reconstruction, adolescent, and risk factor were newly emerged research hot spots.

CONCLUSION

The understanding of FAI has been improved significantly during the past two decades. Present studies focused on identifying the optimal method to treat labral pathology, outcome assessment of either surgeries or conservative managements, and predicting midterm and long-term outcomes. Together these studies exert critical implications for decision-making and management for FAI.

Hip Arthroscopy in Smokers: A Systematic Review of Patient-Reported Outcomes and Complications in 18,585 Cases

BACKGROUND

Although the negative effects of smoking have been documented for other types of arthroscopic procedures, there is limited information regarding its influence on hip arthroscopy outcomes.

PURPOSE

To examine the effect of smoking on the following outcomes after hip arthroscopy: patient-reported outcomes (PROs), the degree of improvement in PROs relative to baseline, complication rates, and rates of revision arthroscopy and/or conversion to total hip arthroplasty (THA).

STUDY DESIGN

Systematic review.

METHODS

The PubMed, Embase, and Cochrane Library databases were queried for studies published between January 1, 1985, and January 14, 2020, comparing the outcomes of hip arthroscopy between smokers and nonsmokers. Case reports, basic science studies, and studies investigating pediatric patients or lacking a description of outcomes were excluded. Included outcome tools were the modified Harris Hip Score, the visual analog scale (VAS) for pain and satisfaction, and the Hip Outcome Score (HOS)-Sports Specific and HOS-Activities of Daily Living. Preoperative characteristics and operative indications were also recorded.

RESULTS

Postoperative combined means (± SD) were better in nonsmokers versus smokers for the modified Harris Hip Score (75.67 ± 20.88 vs 82.32 ± 15.5; P = .001), the VAS pain (3.13 ± 2.79 vs 2.13 ± 2.21; P < .001), and the HOS-Sports Specific (62.54 ± 25.38 vs 71.7 ± 23.3; P < .001). There was no difference between groups in VAS satisfaction (P = .23) or HOS-Activities of Daily Living (P = .13). The extent of PRO score improvement relative to baseline values was similar in smokers and nonsmokers in all PRO measures (P > .05 for all). Smokers demonstrated higher rates of postoperative thromboembolic (P = .0177) and infectious (P = .006) complications. There was no difference between rates of revision arthroscopy (P = .47) and THA conversion (P = .31).

CONCLUSION

Smoking adversely affects certain postoperative PROs and is associated with higher postoperative complication rates. Further studies are required investigating the degree of PRO improvement and long-term arthroscopy revision and THA conversion rates.

Using a simplified version of a common surgical grading scale for acetabular labral tears improves the utility of preoperative hip MRI for femoroacetabular impingement

OBJECTIVE

To evaluate whether a commonly used surgical grading scale, when applied to acetabular labral findings on MRI, could improve preoperative planning and counseling for patients undergoing hip arthroscopy.

MATERIALS AND METHODS

We evaluated 76 clinical MRIs performed on patients with femoroacetabular impingement. Three musculoskeletal radiologists and one musculoskeletal fellow reviewed each scan in a blinded fashion, classifying the acetabular labrum from 12:00 to 4:00 using the Beck scale, a common surgical grading scale. Clinical correlation was provided via surgical examination and classification. Reliability was determined between readers and between reader and surgical data using Cohen's kappa and Krippendorff's alpha at each clock position and for the worst grading for each scan. In addition, a simplified version of the scale comprised of only two grades, potentially reparable and not potentially reparable, was evaluated.

RESULTS

When the scale was simplified into categories of potentially reparable and not potentially reparable, the sensitivity was excellent, ranging from 85.5 to 96%. Observer agreement when using individual Beck grades was found to range from poor to fair; Kappa ranged from 0.03 to 0.19, and Alpha ranged from - 0.27 to 0.22.

CONCLUSION

The simplified version of the Beck labral scale when applied to MRI is a highly sensitive predictor of potentially reparable labral pathology while excluding normal and grossly degenerative tissue. Use of this scale provides clinically relevant information that can drive preoperative planning and improve patient counseling. It does so in a standardized fashion that can be applied across practice sites and without additional cost.

Low Self-Efficacy and High Kinesiophobia Are Associated With Worse Function in Patients With Femoroacetabular Impingement Syndrome

CONTEXT

Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS.

OBJECTIVE

(1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety.

DESIGN

Cross-sectional.

SETTING

University health center.

PARTICIPANTS

Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2).

MAIN OUTCOME MEASURES

Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function.

RESULTS

The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01).

CONCLUSION

Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.

What Is the Survivorship After Hip Arthroscopy for Femoroacetabular Impingement? A Large-database Study

BACKGROUND

Patients with femoroacetabular impingement (FAI) may experience lasting clinical improvement after hip arthroscopy; however, some patients will still eventually undergo early conversion to THA due to unresolved symptoms and progression of arthritis. However, the risk of this has been only incompletely characterized in prior studies.

QUESTIONS/PURPOSES

Using a large healthcare claims database over a 5-year period (2011-2016), we asked: (1) What is the survivorship free from THA after arthroscopic osteoplasty performed for FAI? (2) What identifiable demographic factors and patient characteristics are associated with early conversion to THA after hip arthroscopy performed for FAI?

METHODS

We included all patients who underwent hip arthroscopy for FAI, between the ages of 12 years and 63 years, with 3 months of claims data before hip arthroscopy and minimum 2-year follow-up. A total of 4730 hip arthroscopy patients from 2011 to 2014 were retrieved from a US commercial claims database. Hip arthroscopy incidence doubled over time from 1.2 to 2.1 persons per 100,000. Temporal trends, patient demographics, diagnoses at time of arthroscopy, and patient comorbidities were retrieved and logistic regression performed. Survivorship analysis on 11,323 patients (lifting the 2-year follow-up requirement) was also performed to identify independent variables associated with early risk of conversion to THA.

RESULTS

In patients undergoing hip arthroscopy for FAI, the overall proportion of conversion to THA within 2 years after hip arthroscopy was 7% (338 of 4730). After controlling for confounding variables such as sex, obesity, and depression, we found the following were independently associated with increased odds of conversion to THA: older age (odds ratio 1.08 [95% CI 1.01 to 1.10]; p < 0.001), osteoarthritis (OR 2.91 [95% CI 2.27 to 3.77]; p < 0.001), joint inflammation (OR 1.89 [95% CI 1.16 to 3.09]; p = 0.01), and a history of opioid use (OR 2.17 [95% CI 1.69 to 2.79]; p < 0.001). Survivorship analysis similarly revealed that older age (hazard ratio 1.08 [95% CI 1.07 to 1.09]; p < 0.001), osteoarthritis (HR 2.53 [95% CI 2.13 to 3.01]; p < 0.001), joint inflammation (HR 1.53 [95% CI 1.10 to 2.11]; p = 0.01), a history of opioid use (HR 2.02 [95% CI 1.71 to 2.38]; p < 0.001), and smoking (HR 1.55 [95% CI 1.14 to 2.11]; p = 0.005), were independently associated with increased odds of conversion to THA within 2 years after hip arthroscopy for FAI.

CONCLUSIONS

Although the findings of this study are limited and should not be taken in isolation, patients with FAI who are older, carry diagnoses of inflammatory or degenerative articular disease, or who use opioids or smoke should be counseled about a potentially increased risk of undergoing early conversion to THA after hip arthroscopy. Future studies to further examine the effect of these diagnoses in prospectively collected cohorts, incorporating radiographic and patient-reported outcome measures, are needed.

LEVEL OF EVIDENCE

Level III, prognostic study.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R ² = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

Associations of preoperative patient mental health status and sociodemographic and clinical characteristics with baseline pain, function, and satisfaction in patients undergoing primary shoulder arthroplasty

HYPOTHESIS AND BACKGROUND

Shoulder pain and dysfunction are common indications for shoulder arthroplasty, yet the factors that are associated with these symptoms are not fully understood. This study aimed to investigate the associations of patient and disease-specific factors with preoperative patient-reported outcome measures (PROMs) in patients undergoing primary shoulder arthroplasty. We hypothesized that worse mental health status assessed by the Veterans RAND 12-Item Health Survey (VR-12) mental component score (MCS), glenoid bone loss, and increasing rotator cuff tear severity would be associated with lower values for the preoperative total Penn Shoulder Score (PSS) and its pain, function, and satisfaction subscores.

METHODS

We prospectively identified 12 patient factors and 4 disease-specific factors as possible statistical predictors of preoperative PROMs in patients undergoing primary shoulder arthroplasty at a single institution over a 3-year period. Multivariable statistical modeling and Akaike information criterion comparisons were used to investigate the unique associations with, and relative importance of, these factors in accounting for variation in the preoperative PSS and its subscores.

RESULTS

A total of 788 cases performed by 12 surgeons met the inclusion criteria, with a preoperative median total PSS of 31 points (pain, 10 points; function, 18 points; and satisfaction, 1 point). As hypothesized, a lower VR-12 MCS was associated with lower preoperative PSS pain, function, and total scores, but patients with intact status or small to medium rotator cuff tears had modestly lower PSS pain subscores (ie, more pain) than patients with large to massive superior-posterior rotator cuff tears. Glenoid bone loss was not associated with the preoperative PSS. Female sex and fewer years of education (for all 4 outcomes), lower VR-12 MCS and preoperative opioid use (for all outcomes but satisfaction), and rotator cuff tear severity (for pain only) were the factors most prominently associated with preoperative PROMs.

CONCLUSION

In addition to mental health status and rotator cuff tear status, patient sex, years of education, and preoperative opioid use were most prominently associated with preoperative PROMs in patients undergoing shoulder arthroplasty. Further studies are needed to investigate whether these factors will also predict postoperative PROMs.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia.

PURPOSE

To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models.

RESULTS

We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; P < .001), and they reported worse postoperative PROM scores compared with nonimpaired patients (weighted mean difference, -20.2 points; 95% CI, -32.9 to -7.5; P < .001).

CONCLUSION

Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor.

REGISTRATION

CRD42019124836 (PROSPERO).

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Patient characteristics do not predict the change in physical functioning following arthroplasty measured by the HOOS-PS and KOOS-PS

Predicting personalized outcome after arthroplasty improves shared decision-making. The aim of this paper was to determine predictors of functional outcome measured by the Hip disability and Osteoarthritis Outcome Score - Physical function Shortform (HOOS-PS) or Knee injury and Osteoarthritis Outcome Score - Physical function Shortform (KOOS-PS) in patients undergoing total hip (n = 79) or total knee arthroplasty (n = 90) respectively. Patients were assessed at baseline and following arthroplasty. A multiple regression analysis showed that the included variables predicted the change score in HOOS-PS limited (F (8,66) = 3.139, p = 0.005, adjusted R2 = 0.188) and the KOOS-PS not significantly (F (8,73) = 0.837, p = 0.573, adjusted R 2  = -0.016). Concluding, baseline characteristics cannot be used for personalized prediction using the KOOS-PS and HOOS-PS.

The impact of mental health disorders on outcomes following hip arthroscopy for femoroacetabular impingement syndrome: a systematic review

Hip arthroscopy for femoroacetabular impingement syndrome (FAI) has been shown to be beneficial in the short- to medium-term though outcomes vary between individuals. Multiple factors have been suggested to affect outcomes including pre-operative mental health disorders. We undertook a systematic review to assess the evidence relating to the effect of pre-existing mental health disorders on the outcomes following hip arthroscopy for FAI. Following PRISMA guidelines, a multi-database search was undertaken using three key concepts: 'mental health', 'FAI' and 'hip arthroscopy'. Results were screened and data extracted from relevant studies. A total of six studies met the inclusion criteria including 2248 hips, all published between 2017 and 2019. All studies were of evidence level III or IV with reasonable methodological quality. One study demonstrated pre-operative depression to be related to altered pain reduction in the short-term following surgery. Three studies reported inferior outcomes in the medium-term (1-2 years) in those with worse mental health. One study demonstrated an increased risk of persistent pain 2 years following surgery and one a reduced chance of returning to active military service following surgery in those with worse mental health. Despite inferior outcomes individuals with mental health disorders did still benefit from surgery in general. In conclusion, the presence of pre-existing poor mental health is associated with inferior outcomes in the medium-term following arthroscopic surgery for FAI. Surgeons should consider screening patients for mental health disorders before surgery and counselling them appropriately as to the potential for less satisfactory surgical outcomes.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With a Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.

PURPOSE

To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m²) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.

CONCLUSION

The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.

Clinical Outcomes of Hip Arthroscopy in Patients With Systemic Inflammatory Diseases Compared With Matched Controls at a Minimum of 2-Year Follow-Up

PURPOSE

To evaluate postoperative outcomes and preoperative risk factors for patients with underlying systemic inflammatory disorders after hip arthroscopy.

METHODS

A retrospective analysis of patients who had undergone hip arthroscopy, with a history of systemic inflammatory disease, was performed. This included patients with a diagnosis of lupus, a positive antinuclear antibody test, rheumatoid arthritis, psoriatic arthritis, sarcoidosis, inflammatory bowel disease, Reiter syndrome, and mixed connective tissue disease. These cases were 1:2 matched to a control group of patients with no history of systemic inflammatory disease based on age and sex. An a priori power analysis was conducted and A 1:2 case-control ratio was selected to increase study power. Inclusion criteria included all skeletally mature patients with hip pain refractory to nonoperative management who underwent hip arthroscopy for labral tears and femoroacetabular impingement. Skeletally immature patients, those with Tönnis grades of 2 or more (less than 2 mm of joint space), hip dysplasia, patients undergoing revision hip arthroscopy, and patients whose pain failed to improve after intra-articular injection were excluded. The primary outcome was rate of revision hip arthroscopy or total hip arthroplasty 24 months after surgery. Secondary outcomes included 2 patient-reported outcome scores, the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS).

RESULTS

Twenty patients (21 hip arthroscopy procedures) and 42 controls were included. There was no significant difference in proportion of patients who met failure criteria (28.6% vs 16.7%, P = .271) or 2-year survivorship (76.2% vs 83.3%, P = .496) between the systemic inflammatory disorder and control groups, respectively. Both groups had a significant improvement in mHHS and NAHS at 24 months compared with baseline; however, there was no significant difference in mHHS (P = .28) or NAHS (P = .22) at 24 months between the 2 groups.

CONCLUSIONS

Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database

PURPOSE

To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety.

METHODS

Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy.

RESULTS

Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001).

CONCLUSIONS

Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

Defining Meaningful Functional Improvement on the Visual Analog Scale for Satisfaction at 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To (1) define Substantial Clinical Benefit (SCB), Patient Acceptable Symptomatic State (PASS), and Minimal Clinically Important Difference (MCID) for the visual analog scale (VAS) Satisfaction in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS), and (2) identify preoperative predictors of achieving each outcome end-point.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and January 2017 were prospectively collected and retrospectively analyzed. Inclusion criteria consisted of patients with clinical and radiographic diagnosis of FAIS, who failed nonoperative treatment, underwent primary hip arthroscopy to address the FAIS, and had at minimum 2-year follow-up. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement on the VAS)Satisfaction, we calculated MCID, PASS, and SCB for this outcome measure. A multivariate logistic regression analysis was used to identify preoperative predictors of achieving SCB, PASS, and MCID satisfaction.

RESULTS

A total of 335 patients were included in the final analysis, with an average age and body mass index (BMI) of 32.8 (standard deviation ± 12.4) years and 25.2 (standard deviation ± 5.3), respectively, and the majority being female (69.3%). The values on the VAS satisfaction were identified to represent MCID, PASS, and SCB, respectively: 52.8, 80.9, and 89.7. The rates of achieving clinically significant improvement on the VAS Satisfaction was 85.6%, 68.1%, and 56.9% for MCID, PASS, and SCB, respectively. A larger preoperative alpha angle was predictive for achieving SCB (odds ratio [OR], 1.076; P = .046), whereas lower BMI (OR, 0.955; P = .047) and larger preoperative alpha angle (OR, 1.12; P = .025) were predictors for achieving PASS.

CONCLUSIONS

This study identified threshold VAS satisfaction scores of 52.8, 80.9, and 89.7 for achieving MCID, SCB, and PASS, respectively, at 2-year follow-up following hip arthroscopy for FAIS. Furthermore, preoperative variables including larger preoperative alpha angles and lower BMI are predictors of achieving superior clinical satisfaction.

LEVEL OF EVIDENCE

Level IV, Case Series.

Is the Actual Failure Rate of Hip Arthroscopy Higher Than Most Published Series? An Analysis of a Private Insurance Database

BACKGROUND

The use of hip arthroscopy (HA) for the management of intra-articular hip pathology has increased greatly, with a 600% increase in utilization from 2006-2010. Studies have demonstrated good to excellent outcomes in patients undergoing hip arthroscopy for treatment of femoroacetabular impingement (FAI) syndrome. However, some patients undergoing primary hip arthroscopy will require revision hip arthroscopy (revision HA) or conversion to total hip arthroplasty (THA). The purpose of the present study was to evaluate the association between hip arthroscopy failure and (1) osteoarthritis, (2) age > 40 years, and (3) psychiatric comorbidities.

METHODS

The Humana Inc. insurance claims database was used to identify patients undergoing hip arthroscopy between 2007 and 2015, with query by CPT (current procedural terminology code) of more than 25 million deidentified insurance and Medicare beneficiary claims. Following primary hip arthroscopy, patients were longitudinally tracked for subsequent ipsilateral hip arthroscopy (revision HA) or total hip arthroplasty (THA) with a minimum of 1-year clinical follow-up from the primary HA procedure. Hip arthroscopy failure (HA failure) was defined specifically as patients who underwent a revision HA or THA with a minimum of 1-year of clinical follow-up from the primary HA procedure. Variables assessed included presence of pre-existing osteoarthritis, age < 40 years or age > 40 years, and presence of preoperatively diagnosed psychiatric comorbidities including depression or anxiety. The relationships between revision HA, THA, or HA failure and these variables were assessed utilizing univariate and multiple logistic regression analysis. Independent predictors of revision ipsilateral hip arthroscopy and subsequent hip arthroplasty were identified using multiple logistic regression.

RESULTS

In total, 785 patients (64.1% female) underwent primary hip arthroscopy. The overall failure rate with a minimum of 1-year clinical follow-up from the index HA procedure was 18%[140/785; 8% (63/785) revision hip arthroscopy, 10% (82/785) THA]. Multivariable logistic regression analysis identified psychiatric comorbidities (Odds Ratio [OR] 2.8, 95% Confidence Interval [CI] 1.2-6.2, p<0.01) as the only independent predictor of hip arthroscopy failure (revision HA or THA). Independent predictors of revision HA included both psychiatric comorbidity (OR 2.8, 95% CI 1.2-6.2, p<0.01) and age < 40 years (OR 2.6, 95% CI 1.4-5.0, p<0.01), while age > 40 years (OR 3.09, 1.47-7.25, p<0.005), smoking (OR 2.05, 95% CI, 1.68-1.88, p=0.02), and osteoarthritis (OR 3.24, 95% CI 1.98-5.43, p<0.001) predicted conversion to THA.

CONCLUSION

The hip arthroscopy failure rate of 18% in the present study is alarmingly high, a figure much higher than reported in previously published series. Patient factors associated with conversion to THA included age > 40 years, smoking, and preexisting osteoarthritis. The presence of psychiatric comorbidities, specifically depression and anxiety, was independently associated with revision HA and overall HA failure.Level of Evidence: III.

Preoperative Predictors of Achieving Clinically Significant Athletic Functional Status After Hip Arthroscopy for Femoroacetabular Impingement at Minimum 2-Year Follow-Up

PURPOSE

To identify predictors of achieving clinically significant sport function in athletic patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data were analyzed for all patients who treated for FAIS between 2012 to 2016 and reported being athletes, including recreational and competitive athletes. All patients had a minimum of 2-year follow-up with patient-reported athletic function in the form of the Hip Outcome Score-Sport Specific (HOS-SS), visual analog score-pain, and patient satisfaction. Achieving clinically significant sports function was defined as either reaching the minimally clinical important difference (MCID) or the patient acceptable symptomatic state (PASS) for HOS-SS at 2-year follow-up. An exploratory factor analysis was used to determine specific domains for the predictor variables and to reduce the redundancy in these variables. A logistic regression analysis was used to identify significant predictors of achieving clinically significant sports function [corrected].

RESULTS

Of 780 qualifying patients, 626 completed the 2-year minimum follow-up (80%), with a mean age and body mass index of 31.6 ± 11.9 years and 24.6 ± 8.6, respectively. A total of 500 patients (86.5%) achieved high functional status, with 77.9% achieving MCID HOS-SS and 68.7% achieving PASS HOS-SS. Logistic regression analysis identified increased the α angle (odds ratio [OR] 0.976; P = .027), preoperative pain duration (OR 0.729; P = .011), and body mass index (BMI) (OR 0.919; P = .018), as well as the presence of femoral chondral defects (OR 0.769; P = .013), as negative predictors for achieving MCID. Negative predictors for achieving PASS HOS-SS included the presence of a preoperative limp (OR 0.384; P = .013), anxiety or depression (OR 0.561; P = .041), and increased BMI (OR 0.945; P = .018) and preoperative pain duration (OR 0.987; P < .001).

CONCLUSIONS

Several predictors of achieving clinically significant sport function performance exist, including a history of anxiety or depression, BMI, preoperative α angle, limp, femoral chondral damage, *and preoperative symptom duration. Our results suggest there are both modifiable and nonmodifiable preoperative factors that have the potential to predict achieving high athletic function after hip arthroscopy for FAIS.

LEVEL OF EVIDENCE

IV, Case Series.

How Can We Define Clinically Important Improvement in Pain Scores After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? Minimum 2-Year Follow-up Study

BACKGROUND

Patient postoperative pain is being increasingly reported in the field of hip preservation surgery. The visual analog scale (VAS) for pain is one of the most commonly utilized measures for perioperative pain assessment. Currently, there is limited understanding of clinically significant improvement in VAS pain.

PURPOSE

(1) To define the substantial clinical benefit (SCB), patient acceptable symptomatic state (PASS), and minimal clinically important difference (MCID) for the VAS pain score in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome after 2 years from surgery and (2) to identify preoperative predictors of achieving each outcome endpoint.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy between November 2014 and March 2017 were collected and analyzed. Baseline data and postoperative patient-reported outcome scores were recorded at 2 years postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the MCID, PASS, and SCB were calculated.

RESULTS

A total of 976 patients were included in the final analysis. The VAS pain score threshold for achieving the MCID was defined as a decrease of 14.8; the PASS was defined as achieving a 2-year postoperative score of 21.6 points; and the SCB was defined as a decrease of 25.5 or a score of 15.4 points at 2 years. The rates of achieving the MCID, PASS, and SCB were 97.6%, 66.4%, and 71.2%, respectively. Regression analysis demonstrated that sports involvement, low body mass index, smaller preoperative alpha angle, and absence of articular damage and chondromalacia were predictive of achieving the PASS (all P < .05). Preoperative predictors for achieving the SCB included being male, no smoking history, smaller alpha angle, higher modified Harris Hip Score, and lower VAS pain score (all P < .05).

CONCLUSION

This study identified scores for VAS pain that can be used to define clinically significant outcome after arthroscopic treatment of femoroacetabular impingement syndrome. Specifically, a decrease in pain score of 14.8 was a clinically important improvement in VAS pain, while an absolute score <15.4 or a change of 25.5 represented the upper threshold of VAS pain improvement. Additionally, there were both modifiable and nonmodifiable factors that predicted achieving clinically significant levels of postoperative pain improvement.

No Evidence of Systemic Inflammation in Symptomatic Patients With Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain and represents a major cause of early osteoarthritis. The role of systemic inflammation in pre-arthritic hip conditions remains largely unknown and uninvestigated. Serum-free light chains (sFLCs) are inflammatory markers produced by B cells. This study aimed to determine whether there was evidence of systemic inflammation in patients with FAI, defined by sFLCs, and whether this correlated with markers of disease severity. Participants for this study were recruited from a single center (Nuffield Orthopedic Center, Oxford) and were taking part in the Femoroacetabular Impingement Trial. The cohort comprised 115 individuals (38 male, 77 female, mean age 37 years): 57 individuals received surgical intervention and 58 received physiotherapy. All individuals provided patient-reported outcome measures and serum samples at baseline and follow-up 8 months post-randomization. sFLC concentrations were measured in serum samples by immunoturbidimetry. At baseline, for all individuals, mean polyclonal sFLC concentrations were 30.36 mg/l (standard deviation [SD] 9.23). At follow-up, the mean polyclonal sFLC concentrations were 31.68 mg/l (SD 9.61) in the surgical intervention cohort, and 29.48 mg/l (SD 7.85) in the physiotherapy intervention cohort. There was no significant correlation between sFLC concentrations and any of the patient reported outcome measures, or radiographic measures: average or maximum alpha angle, or center edge angle. In conclusion, in patients with symptomatic FAI there was no systemic inflammation, as defined by sFLC concentrations, and no correlation between sFLC concentrations and measures of disease severity. The lack of inflammation suggests FAI is a mechanical phenomenon. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:2189-2196, 2019.

Do psychological factors or radiographic severity play a role in the age of onset in symptomatic developmental dysplasia of hip and femoroacetabular impingement syndrome?

Background

Age of onset in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement syndrome (FAIS) varies. The purpose of this study was to investigate whether psychological factors, radiographic, and clinical variables were related to age of onset of hip pain in DDH and FAIS.

Methods

We collected demographic, clinical, and radiographic data on 56 DDH and 84 FAIS patients. Each was diagnosed based on radiographic findings and clinical history. Age of onset was operationalized by subtracting patient reported duration of symptoms from patient age at presentation. Pain catastrophizing (PCS) and depression were assessed with the pain catastrophizing scale and hospital anxiety and depression scale (HADS), respectively. Multiple linear regression modeling, with Lasso variable selection, was implemented.

Results

Pain catastrophizing, anxiety, and depression were not significantly related to age of DDH onset (p-values > 0.27) or age of FAIS onset (p-values > 0.29). LASSO-penalized linear regression revealed alpha Dunn angle, Tonnis grade, prior hip surgery, WOMAC pain score, and iHOT total score were associated with age of onset in FAIS (Adjusted R² = 0.3099). Lateral center edge angle (LCEA), alpha frog angle, Tonnis grade, SF12 physical functioning, and body mass index (BMI) were associated with age of DDH onset (Adjusted R² = 0.3578).

Conclusions

Psychological factors, as measured by PCS and HADS, were not associated with age of onset in DDH or FAIS. Functional impairment as measured by WOMAC pain and impaired active lifestyle as measured by iHOT were found to affect age of FAIS onset. For DDH, impaired physical functioning and increasing BMI were found to be associated with age of onset. Severity of the disease, as measured radiographically by LCEA and alpha Dunn angle, was also found to be associated with earlier age of onset in DDH and FAIS, respectively. A patient’s radiographic severity may have more of a relationship to the onset of pain than physiologic factors.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Outcome After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With Minimum 2-Year Follow-up

BACKGROUND

There is a growing trend for hip arthroscopists to treat patients with borderline hip dysplasia (BHD) for femoroacetabular impingement syndrome (FAIS) without addressing the acetabular coverage. However, the literature of outcomes and failure rates for these patients is conflicting.

PURPOSE

(1) To identify whether patients with BHD achieved 2-year similar patient-reported outcome, minimal clinically important difference (MCID), and patient acceptable symptomatic state (PASS) when compared with patients without BHD and (2) to identify predictors for achieving the MCID and PASS among patients with BHD who are undergoing hip arthroscopy for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2017 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA], 20°-25°) were matched 2:1 by age, sex, and body mass index (BMI) to control patients with normal acetabular coverage (LCEA, >25°-40°). Patient-reported outcome, MCID, and PASS were compared between the groups. Multivariate logistic regression analysis identified significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.2, 13.7, 8.5, and 15.2 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific, modified Harris Hip Score, and iHOT-12, respectively. Threshold scores for achieving the PASS in both groups were 87.9, 76.4, 78.1, and 60.0. A total of 112 patients were identified as having BHD (LCEA, 20°-25°) and were matched to 224 controls. Both groups saw statistically significant increases in score averages over the 2-year period; however, the differences between them were not statistically significant (P > .05 for all). There was no statistical difference in the frequency of the BHD and non-BHD cohorts achieving the MCID on at least 1 threshold score (86.6% vs 85.6%, P = .837) and the PASS (78.6% vs 79.8%, P = .79). There was, however, a statistically significant difference between the rates of patients with and without BHD achieving the PASS on the modified Harris Hip Score threshold (62.5% vs 74.5%, P = .028). The final logistic models demonstrated that lower BMI (odds ratio [OR], 0.872; P = .029), lower preoperative alpha angle (OR, 0.965; P = .014), and female sex (OR, 3.647; P = .03) are independent preoperative predictors of achieving the MCID, while lower preoperative alpha angle (OR, 0.943; P = .018) and self-reported limp (OR, 18.53; P = .007) are independent preoperative predictors of achieving the PASS.

CONCLUSION

Outcome improvements in patients with BHD who are undergoing arthroscopic treatment with capsular closure for FAIS are not significantly different from patients with normal acetabular coverage. Lower BMI, lower alpha angle, absence of limp, and female sex are preoperative predictors of achieving meaningful clinically significant outcome improvements in patients with BHD.

Return to Duty After Mini-Open Arthroscopic-Assisted Treatment of Femoroacetabular Impingement in an Active Military Population

Purpose

To report the return-to-duty rate and surgical outcomes in a military population after mini-open arthroscopic-assisted surgery for femoroacetabular impingement (FAI) in an effort to affirm its efficacy.

Methods

A retrospective review of consecutive active-duty patients receiving mini-open arthroscopic-assisted surgery for FAI between 2007 and 2011 was performed. Patients younger than 18 years, non–active-duty patients, and patients with prior hip surgery were excluded. Demographic, radiographic, and duty-status data were collected. The primary outcome measure was a return to duty. Outcome scores were obtained in a proportion of the cohort, including the modified Harris Hip Score, Single Assessment Numeric Evaluation score, Western Ontario and McMaster Universities Osteoarthritis Index score, patient satisfaction score, and Veterans RAND 12 (VR-12) score. All patients had achieved a minimum of 1 year of follow-up at the time of assessment. All P values for significance were set at .05 or lower.

Results

Of 182 patients (average age, 30.4 years), 156 (86%) were available for follow-up with return-to-duty data at an average of 2.8 years (range, 1-6 years). Of the patients, 78% returned to full duty (53%) or returned to duty with restrictions (25%). Outcome scores were available for 101 of 182 patients (55%) with duty rates similar to the total cohort (81% who returned to duty: 58% with no restrictions and 23% with restrictions). Return to duty correlated with improved outcomes compared with those who were medically discharged with respect to the modified Harris Hip Score (68.2 vs 54.5, P < .03), Single Assessment Numeric Evaluation score (48.2 vs 25.3, P < .02), and VR-12 physical (39.7 vs 33.2, P < .05) and VR-12 mental (54.5 vs 43.4, P < .005) scores.

Conclusions

Mini-open arthroscopic-assisted surgery for FAI is successful in returning most service members to duty at short-term follow-up. Return correlates with improved outcome scores, although previously reported minimally clinical important difference and patient acceptable symptomatic state threshold values were not uniformly achieved.

Level of Evidence

Level IV, retrospective case series.

Relationship Between Baseline Patient-reported Outcomes and Demographic, Psychosocial, and Clinical Characteristics: A Retrospective Study

Introduction

Alternative payment models in total lower extremity joint replacement (TJR) increasingly emphasize patient-reported outcomes (PROs) to link the latter to value-based payments. It is unclear to what extent demographic, psychosocial, and clinical characteristics are related to PROs measured preoperatively with the commonly used Hip/Knee Osteoarthritis Outcome Scores (HOOS/KOOS) and the Veterans RAND 12-Item Health Survey (VR-12) questionnaires. We aim to identify (1) the preoperative relationship between HOOS/KOOS and VR-12 scores and several demographic, psychosocial, and clinical patient characteristics and (2) the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Methods

All TJR cases performed in 2017 at the two highest-volume hospitals within an urban academic health system were queried. Preoperative HOOS/KOOS and VR-12 surveys were administered through an e-collection platform. VR-12 physical and mental component scores (PCS, MCS) were generated. Patient information was extracted from the electronic health record. Bivariate and multivariate regression analyses were performed. Odds ratios (ORs) and 95% confidence intervals were reported.

Results

In univariate analysis, patients with HOOS/KOOS, VR-12 PCS, and MCS in the ≤25th percentile group were more likely to have an ASA score of ≥3 compared with those with higher scores. In multivariate analysis, increased and decreased odds of low HOOS/KOOS were associated with a one-unit increase in Charlson Comorbidity Index (OR, 1.16) and VR-12 MCS (OR, 0.97), respectively. Increased odds of low baseline VR-12 PCS and MCS were associated with ASA class ≥3 (OR, 1.65 and 1.40). Decreased odds of a low MCS were associated with an increase in HOOS/KOOS (OR, 0.98) (P ≤ 0.05 for all).

Conclusion

Of the factors that are associated with low baseline PRO scores, preoperatively addressing mismanaged comorbidities, mental health, and physical function were identified as the best modifiable factors for optimization, which may result in improved baseline PROs before TJR.

Validity and efficiency of a smartphone-based electronic data collection tool for operative data in rotator cuff repair

BACKGROUND

This study tested validity and efficiency of Orthopaedic Minimal Data Set (OrthoMiDaS) Episode of Care (OME).

METHODS

We analyzed 100 isolated rotator cuff repair cases in the OME database. Surgeons completed a traditional operative note and OME report. A blinded reviewer extracted data from operative notes and implant logs in electronic medical records by manual chart review. OME and electronic medical record data were compared with data counts and agreement between 40 variables of rotator cuff disease and repair procedures. Data counts were assessed using raw percentages and McNemar test (with continuity correction). Agreement of categorical variables was analyzed using Cohen κ (unweighted) and of numerical variables using the concordance correlation coefficient (CCC). Efficiency was assessed by median time to complete.

RESULTS

OME database had significantly higher data counts for 25% (10/40) of variables. A high level of proportional and statistical agreement was demonstrated between the data. Among 35 categorical variables, proportional agreement was perfect for 17%, almost perfect (0.81 ≤ κ ≤ 1.00) for 37%, substantial (0.61 ≤ κ ≤ 0.80) for 20%, moderate (0.41 ≤ κ ≤ 0.60) for 14%, fair (0.21 ≤ κ ≤ 0.40) for 6%, and slight (0.0 ≤ κ ≤ 0.20) for 6%. Of 5 numerical variables, agreement was almost perfect (CCC > 0.99) for 20% and poor (CCC < 0.90) for 80%. Median OME completion time was 161.5 seconds (interquartile range, 116-224.5).

CONCLUSION

OME is an efficient, valid tool for collecting comprehensive, standardized data on rotator cuff repair.

Biomarkers for Femoroacetabular Impingement and Hip Osteoarthritis: A Systematic Review and Meta-analysis

BACKGROUND

The early recognition and management of patients with hip lesions, such as femoroacetabular impingement (FAI) and early hip osteoarthritis (OA), may preempt significant hip morbidity. The identification of reliable biomarkers may help guide decision making in an efficient and cost-effective manner.

PURPOSE

To determine the biomarkers that have been associated with FAI as well as identify serum, synovial, and urinary analytes that have shown clinical utility in the prediction or identification of hip OA.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

The terms "hip arthroscopy," "femoroacetabular impingement," "labral tear," "osteoarthritis," and "biomarker" were searched in PubMed, Web of Science, Scopus, Cochrane Library, and Google Scholar, yielding 276 articles. After screening, 7 articles were included. Pooled estimates were calculated utilizing a fixed-effects inverse-variance model weighted for individual study size.

RESULTS

A total of 1747 patients with a mean age of 37.5 ± 4.5 years (76.4% female) were identified. Forty-three unique biomarkers were assessed. Although general proinflammatory cytokines IL-1 and TNF-α exhibited inconsistent trends in arthritic hips, IL-6 demonstrated a consistent increase (+84.8% [95% CI, 81.9%-87.6%]; P < .05). A significant difference was found in levels of the fibronectin-aggrecan complex (FAC) in patients with OA compared with controls (0.08 ± 0.40 vs 1.15 ± 0.35 μg/mL, respectively; P < .001). It was the only specific analyte to show a significant difference between those with and without OA. In the setting of FAI, cartilage oligomeric matrix protein (COMP) was significantly increased in athletes after adjusting for concurrent knee and hip OA. A statistically significant difference was present in FAI-positive hips (9.0 ± 0.1 [95% CI, 8.8-9.3]) compared with controls (8.4 ± 0.1 [95% CI, 8.2-8.4]) (P < .05). Other biomarkers, such as CXCL3, which exhibited statistically significant differences compared with controls, did not control for underlying factors such as age and concomitant lesions.

CONCLUSION

COMP and FAC are specific biomarkers with potential utility in the diagnosis and management of FAI and hip OA, given their ability to differentiate between controls and patients with hip lesions. Further research is necessary to identify their ability in determining disease severity, predicting the response to treatment, and establishing an association with the risk of long-term OA.

Survivorship and Outcome of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Performed With Modern Surgical Techniques

BACKGROUND

Hip arthroscopy for femoroacetabular impingement syndrome (FAIS) is a rapidly growing field in sports surgery; however, factors associated with poor outcomes and identification of predictor models of inferior clinical outcomes is unclear.

PURPOSE

To analyze predictors of clinical failure and inferior clinical outcomes among patients undergoing hip arthroscopy for treatment of FAIS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were collected and analyzed from consecutive patients who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS from a single fellowship-trained surgeon between January 2012 and November 2015. Baseline data, postoperative patient-reported outcomes, and rates of clinical failure and inferior clinical outcomes were recorded at 2 years postoperatively. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Inferior clinical outcome was defined as not reaching the minimal clinically important difference (MCID) or patient acceptable symptomatic state for Hip Outcome Score-Activities of Daily Living. A multivariate logistic regression analysis was used to identify significant predictors of clinical failure and inferior clinical outcome.

RESULTS

Out of 1161 eligible patients, 935 (80.5%) completed 2-year postoperative patient-reported outcomes. The mean ± SD age and body mass index were 33.3 ± 12.3 years and 25.4 ± 8.2 kg/m², respectively. The overall clinical failure rate was 3.6% (n = 34), including 23 cases (2.5%) of revision hip arthroscopy and 11 cases (1.2%) of conversion to total hip arthroplasty. Predictors of clinical failure were lower preoperative International Hip Outcome Tool score ( P = .016), chronic preoperative pain ( P = .001), and chondromalacia in the affected hip ( P = .04). The inferior clinical outcome group, consisting of those who failed to reach the MCID for Hip Outcome Score-Activities of Daily Living, included 256 patients (27.4%). Predictors of inferior clinical outcomes were Tönnis grade >1 ( P = .01), workers' compensation ( P < .001), and increased body mass index ( P = .02).

CONCLUSION

This study demonstrates that 73% of all patients treated for symptomatic FAIS with primary hip arthroscopy and routine capsular closure achieved the MCID. Clinical failure is predicted by a number of modifiable and nonmodifiable factors, including chronic preoperative pain and presence of chondromalacia. The current study updates the midterm failure rates and outcomes achievable with hip arthroscopy for FAIS.