Arthroscopic femoral osteochondroplasty for cam femoroacetabular impingement in patients over 60 years of age

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

Background

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

Purpose

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

Study Design

Cohort study; Level of evidence, 3.

Methods

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

Results

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

Conclusion

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

Incidence of Venous Thromboembolism After Hip Arthroscopy Is Low With or Without Prophylaxis but Risk Factors Include Oral Contraceptive Use, Obesity, and Malignancy

PURPOSE

To determine the incidence of and risk factors for symptomatic venous thromboembolism (VTE) after hip arthroscopy (HA) and thromboprophylaxis prescription utilization for this procedure.

METHODS

The PearlDiver Mariner database was queried using Current Procedural Terminology codes to identify adult patients (aged ≥ 18 years) who underwent HA between 2010 and 2020. Patient demographic information, including age, oral contraceptive use, and medical comorbidities, as well as perioperative thromboprophylaxis utilization, was recorded using International Classification of Diseases codes and National Drug Codes. The incidence of postoperative VTE within 90 days was determined. Multivariate logistic regression was used to identify predictors of perioperative thromboprophylaxis utilization and risk factors for VTE.

RESULTS

The queried records identified 60,181 patients who met the inclusion criteria. Of these patients, 367 (0.6%) experienced VTE, including deep venous thrombosis (0.5%) and/or pulmonary embolism (0.2%). Approximately 2.1% of patients used thromboprophylaxis, including aspirin (1.1%), low-molecular-weight heparin (0.9%), and oral factor Xa inhibitors (0.1%). Oral contraceptive pill use (adjusted odds ratio [aOR], 2.16; 95% confidence interval [CI], 1.34-3.46), obesity (aOR, 1.37; 95% CI, 1.05-1.79), and a history of malignancy (aOR, 1.69; 95% CI, 1.12-2.54) were associated with increased odds of experiencing VTE. Perioperative thromboprophylaxis (aOR, 0.52; 95% CI, 0.19-1.39) was not significantly associated with decreased odds of experiencing VTE. However, obesity (aOR, 1.17; 95% CI, 1.00-1.38) and hypertension (aOR, 1.17; 95% CI, 1.02-1.36) were associated with increased odds of thromboprophylaxis prescription utilization.

CONCLUSIONS

Although the overall risk of symptomatic VTE after HA remains low, oral contraceptive use, obesity, and a history of malignancy are associated with increased odds of thromboembolic events within 90 days. Routine thromboprophylaxis after HA may not be indicated in all patients but can be considered based on patient-specific risk factors.

LEVEL OF EVIDENCE

Level III, retrospective prognostic comparative trial.

Ten-year outcome following surgical treatment of femoroacetabular impingement

Aims

The primary aim of this study was to determine the ten-year outcome following surgical treatment for femoroacetabular impingement (FAI). We assessed whether the evolution of practice from open to arthroscopic techniques influenced outcomes and tested whether any patient, radiological, or surgical factors were associated with outcome.

Methods

Prospectively collected data of a consecutive single-surgeon cohort, operated for FAI between January 2005 and January 2015, were retrospectively studied. The cohort comprised 393 hips (365 patients; 71% male (n = 278)), with a mean age of 34.5 years (SD 10.0). Over the study period, techniques evolved from open surgical dislocation (n = 94) to a combined arthroscopy-Hueter technique (HA + Hueter; n = 61) to a pure arthroscopic technique (HA; n = 238). Outcome measures of interest included modes of failures, complications, reoperation, and patient-reported outcome measures (PROMs). Demographic, radiological, and surgical factors were tested for possible association with outcome.

Results

At a mean follow-up of 7.5 years (SD 2.5), there were 43 failures in 38 hips (9.7%), with 35 hips (8.9%) having one failure mode, one hip (0.25%) having two failure modes, and two hips (0.5%) having three failure modes. The five- and ten-year hip joint preservation rates were 94.1% (SD 1.2%; 95% confidence interval (CI) 91.8 to 96.4) and 90.4% (SD 1.7%; 95% CI 87.1 to 93.7), respectively. Inferior survivorship was detected in the surgical dislocation group. Age at surgery, Tönnis grade, cartilage damage, and absence of rim-trimming were associated with improved preservation rates. Only Tönnis grade was an independent predictor of hip preservation. All PROMs improved postoperatively. Factors associated with improvement in PROMs included higher lateral centre-edge and α angles, and lower retroversion index and BMI.

Conclusion

FAI surgery provides lasting improvement in function and a joint preservation rate of 90.4% at ten years. The evolution of practice was not associated with inferior outcome. Since degree of arthritis is the primary predictor of outcome, improved awareness and screening may lead to prompt intervention and better outcomes.

Cite this article: Bone Jt Open 2022;3(10):804–814.

Hip Arthroscopy Improves Outcomes With Moderate Conversion to Total Hip Arthroplasty Rates in Patients Aged 50 Years or Older: A Systematic Review

PURPOSE

The purpose of this systematic review was to assess the indications, outcomes, and complications of hip arthroscopy in individuals 50 years of age or older over the past 5 years.

METHODS

The electronic databases PUBMED, MEDLINE, and EMBASE were searched on March 3, 2022, for studies assessing the use of primary hip arthroscopy for patients aged 50 years or older from the past 5 years. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively.

RESULTS

Overall, 17 studies were included, consisting of 6,696 patients (37.5%) with a mean age of 61.4 ± 5.0 years and a median follow-up of 24 months (range: 1.4-70.1). Indications for hip arthroscopy in patients aged 50 years or older were unspecified/undefined (93.8%), mixed pathology (i.e., combined femoroacetabular impingement [FAI], labral tear, osteoarthritis, etc.) (2.7%), and FAI (2.6%). Eleven studies demonstrated significant improvement in functional outcome scores from baseline to final follow-up. Of the 6 studies that compared outcomes across multiple age groups, 3 demonstrated significantly worse functional outcomes, and 2 demonstrated significantly higher rates of conversion to THA for older patients compared to younger patients. Lastly, the overall complication rates ranged from 0 to 38.3%. The rate of conversion to THA ranged from 0 to 34.6%, occurring between 6 and 60 months postoperatively.

CONCLUSIONS

Hip arthroscopy for patients aged 50 years or older yields significant improvements in patient-reported outcomes postoperatively compared to baseline, with a moderate rate of conversion to THA (range: 0 to 34.6%). Clinicians should consider patient history (e.g., imaging, comorbidities, etc.) and values when electing for hip arthroscopy in the older population.

LEVEL OF EVIDENCE

IV, systematic review of Level III and IV studies.

Prognostic Factors for Conversion to Arthroplasty after Hip Arthroscopy. Review of the Literature

Arthroscopic techniques in the treatment of femoroacetabular impingement have experienced an exponential increase over recent years for both diagnosis and treatment. The main risks with treatment are poor clinical outcomes and the conversion to prosthesis. Better knowledge and understanding of the various risk factors leading to prosthesis will improve patient selection for arthroscopic treatments rendering better results. The published papers that have been selected are related to series of hip arthroscopies with risk factors that lead to total hip arthroplasty (THA), in the PubMed database, without a time limit, number of patients, or follow-up time. We selected over 302 papers, 19 papers that show risk factors for conversion to THA. The main risk factors found were femoral chondropathy grade III/IV (relative risk 58.1-12 times increased), acetabular (20-2.96 times), an articular space <2 mm (39-4.26 times), age (14.6-1.06 times), Tönnis 2 in radiographic studies (7.73-3.1 times), obesity (5.6-2.3 times), and osteoarthritis (4.6-2.4 times). There are several risk factors which in an isolated way, highly increase the risk of THA. Some of them have a clear relationship (chondropathy, reduced joint space, Tönnis 2, and osteoarthritis). Based on the review we observed that the elements that are most associated with a conversion to THA after a hip arthroscopy are a high degree of femoral and acetabular chondropathy, a reduced joint space below 2 mm, older age, Tönnis 2, obesity, and hip osteoarthritis.

High Risk of Conversion to THA After Femoroacetabular Osteoplasty for Femoroacetabular Impingement in Patients Older than 40 Years

BACKGROUND

Femoroacetabular impingement (FAI) is a recognized cause of hip pain and decreased quality of life and has been linked to primary idiopathic hip osteoarthritis (OA). Although the operative indications for FAI have expanded to include older patients, we do not know whether there is an increased risk of conversion to THA after femoroacetabular osteoplasty (FAO) via the mini-open approach for FAI in patients older than 40 years compared with younger patients, after controlling for other confounding variables.

QUESTIONS/PURPOSES

(1) After matching for gender, BMI, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of chondral lesion, are patients older than 40 years who undergo FAO for FAI more likely to be revised to THA at a minimum of 2 years' follow-up than are patients younger than 40? (2) Is there a difference in delta (postoperative minus preoperative) improvement in functional outcome scores in those patients who did not go on to THA between patients older than and younger than 40 years?

METHODS

Between 2003 and 2017, one surgeon performed 281 FAOs via the mini-open approach in patients older than 40 years and 544 of the same procedure in patients younger than 40 years. During that period, the general indications for FAO were the same in both age groups: (1) history and physical exam consistent with FAI, (2) radiographic evidence of focal impingement (cam, pincer, or both), (3) evidence of labral or chondrolabral tears, and (4) minimal to no arthritic changes (all four criteria required). In general, age was not used as a contraindication for surgery. A total of 86% (241 of 281) of patients older than 40 and 91% (494 of 544) of those younger than 40 were available for minimum of 2 years' follow-up, had complete datasets (radiographs as well as preoperative and most recent patient-reported outcomes scores) at a minimum of 2 years after surgery, and were considered eligible for the match. Propensity score matching was used to match for BMI, gender, preoperative symptomatic period, surgeon experience, Tönnis grade, and degree of intraoperative chondral lesion. We matched at a 1:2 ratio 130 patients older than age 40 with 260 patients younger than age 40. The mean ± SD follow-up duration for both groups was 5 ± 2 years. The mean age of the cohort of interest was 47 ± 5 years compared with 28 ± 7 years in the control. Fifty-four percent (70 of 130) of patients older than 40 years were women and 46% (60 of 130) were men; for those younger than 40, 51% (133 of 260) of participants were women and 49% (127 of 260) were men. Tönnis grade distribution for patients older than 40 was as follows: 46% (60 of 130) had Grade 0, 42% (55 of 130) had Grade 1, and 12% (15 of 130) had Grade 2. In comparison, Tönnis grade for patients younger than 40 was as follows: 52% (136 of 260) had Grade 0, 38% (100 of 260) had Grade 1, and 9% (24 of 260) had Grade 2 (p = 0.49). Chondral lesion degree was determined intraoperatively as none, a partial-thickness tear, or a full-thickness tear. Tönnis grade was determined based on preoperative plain AP hip radiographs. We then compared the percentage of patients who converted to THA during the surveillance period (our primary study outcome). We also compared the difference in delta (preoperative minus postoperative) improvement in functional outcome scores using the modified Harris Hip Score (mHHS) between the groups, excluding those who had already been converted to THA.

RESULTS

In patients older than 40 years, 16% (21 of 130) converted to THA at a mean time to conversion of 2 ± 1 years compared with 7% (17 of 260) at a mean time of 2 ± 2 years in patients younger than 40 years (p = 0.01). At a mean of 5 ± 2 years after FAO, among those patients who had not undergone conversion to THA, the mean delta mHHS score for patients older than 40 was 11 ± 17, compared with 20 ± 26 for patients younger than 40 (p = 0.04).

CONCLUSION

Since approximately 1 in 6 patients older than 40 years in this series who underwent FAO for FAI opted for early conversion to THA at a mean time of 2 years after the osteoplasty procedure, and the remaining patients who did not undergo THA reported lower improvement in functional outcomes, we recommend surgeons avoid this procedure in patients in this age group until or unless we can better refine our indications. This is especially true because loss to follow-up causes us to believe that, if anything, our estimates of the risk of conversion to THA are conservative.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence?

BACKGROUND

With the rapidly growing body of FAI literature in the last decade, improved evidence exists to support FAI surgery. However, it remains unclear how well third-party insurance company's FAI policies have adapted over time to improved evidence. The purpose of this study was (1) to compare the 2020 FAI surgery criteria of four major insurance companies utilizing a multi-center cohort of FAI patients undergoing surgery to identify rates and causes of ineligibility, and (2) to compare the rates of approval based on changes in policy from 2012 to 2020.

METHODS

Four major insurance companies' coverage policies with specific criteria for the surgical treatment of FAI were applied to this population at two time points (2012 and 2020). The policies listed various combinations of age, symptom duration, radiographic signs of FAI, radiographic signs of osteoarthritis, and physical exam findings. A prospective, multi-center cohort of 712 patients (including 45.5% males and 54.5% females with a mean age of 28.7 years) undergoing surgical treatment of FAI was utilized for analysis of insurance policies.

RESULTS

Based on 2020 FAI policies across 4 insurers, 22.5% (range 18.4-28.4%) of FAI patients would be deemed ineligible. In 2012, the average percent exclusion of the four companies was 23.7%. The most likely reason to be excluded was either failure to meet imaging criteria (alpha angle >50° or positive cross-over sign) [13%, n=94]) or the absence of an impingement sign (9%, n=65). Other causes of exclusion were <6-month symptom duration (6%, n=44), age <15 years (4%, n=28), or skeletally immaturity (3%, n=23).

CONCLUSION

Our study shows that despite a six-year span of growing literature and updated policies, nearly 1 in 5 patients diagnosed with FAI would still potentially be denied coverage. This highlights a continued divide between surgeons and insurance companies. There is a major need for improved consensus regarding the diagnosis of FAI and appropriate indications for surgical intervention.Level of Evidence: IV.

Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups

BACKGROUND

Limited evidence exists concerning the effect of age on hip arthroscopy outcomes for femoroacetabular impingement (FAI).

PURPOSE/HYPOTHESIS

The purpose was to investigate patient-reported outcomes (PROs) and clinical failure rates across various age groups in patients undergoing hip arthroscopy for FAI. We hypothesized that older patients would experience lower improvements in PROs and higher clinical failure rates.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 109 of 130 eligible consecutive patients underwent hip arthroscopy for FAI with a minimum 5-year follow-up. Patients were stratified into 3 groups for comparison (ages 15-34, 35-50, and 51-75 years). Clinical survival rates to revision surgery or total hip arthroplasty (THA) were determined by Kaplan-Meier analysis, and PROs were assessed using analysis of variance. Regression analysis was used to determine factors associated with clinical failure and ΔPROs from baseline to 5 years.

RESULTS

The 5-year survival-to-revision rate was 71% (survival time, 69.2 months; 95% CI, 62.8 to 75.5 months). A significant difference in survival to THA was found between groups (P = .030). Being in the older group versus the young and middle-aged groups predicted increased risk of THA conversion (hazard ratio, 5.7; 95% CI, 1.1 to 28.6; P = .035). Overall modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) improved from baseline to 5 years (mHHS, P < .001; NAHS, P < .001). Body mass index (mHHS: beta, -1.2; 95% CI, -2.2 to -0.3; P = .013; NAHS: beta, -1.6; 95% CI, -2.6 to -0.5; P = .005) and baseline PROs (mHHS: beta, -0.8; 95% CI, -1.1 to -0.4; P < .001; NAHS: beta, -0.7; 95% CI, -1.1 to -0.4; P < .001) were predictive of 5-year ΔPROs. A decrease was seen in minimal clinically important difference rates in middle-aged (P = .011) and old (P = .030) groups from 6-month to 5-year outcomes.

CONCLUSION

Although hip arthroscopy for FAI yielded improvements in PROs regardless of age, middle-aged and older patients experienced greater declines in clinical outcomes over time than younger patients. Older patients remain good candidates for arthroscopy despite a greater risk for conversion to THA.

Arthroscopic Treatment of Labral Tears in Patients 65 Years and Older

The purpose of this multicenter study was to investigate the clinical outcomes after hip arthroscopy in a series of patients 65 years and older with labral tears with a minimum 2-year follow-up. Outcome data were prospectively collected and retrospectively reviewed for patients 65 years and older who underwent hip arthroscopy. Outcomes at minimum 2-year follow-up were analyzed using prospectively collected Hip Outcome Score (HOS) and modified Harris Hip Score (mHHS). A paired Student's t test was performed to determine significant differences between pre- and postoperative patient-reported outcome scores. Twenty-six patients were included, with a mean age of 67.7 years (range, 65-75 years) and mean follow-up of 50.5 months. The short-term survivorship rate was 65%, with 9 patients requiring total hip arthroplasty (THA) by latest follow-up. At minimum 2-year follow-up, mean mHHS, HOS-Activities of Daily Living, and HOS-Sports-Specific Subscale for surviving hips were 78.97 (range, 25-100), 78.56 (range, 21.7-100), and 65.93 (range, 2.78-100), respectively. The mean improvements for patients with pre- and postoperative mHHS and HOS-Sports-Specific Subscale were 28 and 36.6 (P=.0005 and P=.003, respectively). The average patient satisfaction was 7.7 on a scale of 10. There were no complications noted in this cohort. This study demonstrated that patients older than 65 years with labral pathology who have failed nonoperative measures obtain modest clinical improvement from hip arthroscopy. This clinical improvement yielded a high patient satisfaction, but due to the potential for subsequent THA in a subset of this population, surgeons should use a rigorous selection criteria and counsel patients appropriately. [Orthopedics. 2020;43(6):e579-e584.].

Does hip preservation surgery prevent arthroplasty? Quantifying the rate of conversion to arthroplasty following hip preservation surgery

Hip arthroscopic surgery for femoroacetabular impingement and periacetabular osteotomy (PAO) for dysplasia is the most commonly used contemporary treatment for these conditions and has been shown to provide pain relief and restore function. What is less understood and perhaps of more interest to health economists, is the role of these procedures in preserving the hip joint and avoiding hip arthroplasty. The aim of this systematic review was to determine whether hip joint preservation surgery, indeed, preserves the hip joint by looking at conversion rates to total hip arthroplasty (THA). Two separate searches were undertaken, using PRISMA guidelines and utilizing PubMed and Open Athens search engines, identifying manuscripts that looked at conversion to THA following either hip arthroscopy (HA) or PAO. When considering HA, we found 64 eligible papers. Out of these studies, there were 59 430 hips with 5627 undergoing conversion to THA (9.47% [95% CI 9.23–9.71%]) with a mean conversion time of 24.42 months. Regarding PAO, there were 46 eligible papers including 4862 patients who underwent PAO with subsequent conversion to THA in 404 patients (8.31% [95% CI 7.54–9.12%]). with a mean conversion time of 70.11 months. Certain features were associated with increased conversion rates, including increasing age, worsening arthritis and joint space <2 mm. This study demonstrates that the mean conversion rates to be <10% for HA and PAO, during the mean follow-up periods of included manuscripts. Joint preserving surgery appears to defer or at least delay the need for THA.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

II.

Functional Outcomes of Arthroscopic Treatment in Femoroacetabular Impingement in Patients over 60 Years Old Compared with Patients Aged 40 Years or Younger

Objective  To evaluate the functional outcomes of patients diagnosed with femoroacetabular impingement (FAI) older than 60 years, compared with those of patients of age 40 years or younger.

Methods  This was a retrospective review of patients with FAI who underwent hip arthroscopy between 2010 and 2015. The patients were adults aged over 60 years with Tönnis ≤ 1 matched in a 1:1 ratio with adults aged 40 years or younger, according to the type of deformity (cam, pincer, or mixed), sex, and the date when the surgery was performed.

Results  Thirty-four patients were included in each group. The mean age was 30.6 ± 6.9 years and 65.6 ± 4.6 years in the control and case groups, respectively. There were no significant differences between the groups at 1-year follow-up ( p  > 0.05). In the group with older patients (case group), we observed a change in the total Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score from 46.3 to 22.0 in the 1 ^st postoperative year, while the control cases improved in the WOMAC score from 38.1 to 7.2 in relation to the preoperative stage.

Conclusion  In the group of patients ≤ 40 years old, a considerable change was observed in the WOMAC score without a statistical significance compared with the > 60 years group. This observation suggests that hip arthroscopy is beneficial when there is an appropriate selection of patients with FAI, regardless the age of the patient.

Midterm-clinical Outcomes after Hip Arthroscopy in Middle-aged Patients with Early Osteoarthritis

Purpose

Although the number of hip arthroscopies is rapidly increasing in non-elderly patients, outcomes of this procedure in middle-aged patients are not well documented or clearly understood. The purpose of this study was to evaluate the clinical and radiological outcomes after hip arthroscopy in middle-aged patients with early osteoarthritis.

Materials and Methods

This retrospective study analyzed 189 patients with early osteoarthritis of various diagnoses aged 40 years or older who underwent hip arthroscopy between January 2010 and December 2015. Clinical (e.g., modified Harris hip score [mHHS], hip outcome score-activities of daily living [HOS-ADL], visual analogue scale [VAS] for pain, range of motion) and radiological (change of Tönnis grade) outcomes were assessed at a minimum of 3-year follow-up.

Results

The mean preoperative and final mHHS and HOS-ADL improved from 61.2 and 60.6 to 79.5 and 81.8, respectively, while the VAS pain score decreased from 6.3 to 3.2 (P<0.001). Although the mean range of internal rotation and flexion increased from 14.2 and 100.7° preoperatively to 30.4 and 110.6° at 1-year postoperatively, they decreased slightly to 27.4 and 105.4° at the final follow-up, respectively. Eight cases (4.2%) underwent revision arthroscopic surgery and three cases (1.6%) were converted to total hip arthroplasty.

Conclusion

Patients with early-stage osteoarthritis of various diagnoses achieved improved clinical outcomes. Therefore, using hip arthroscopy in middle-aged patients with early osteoarthritis, it is possible to achieve good surgical options.

Patients aged in their 70s do not have a high risk of progressive osteoarthritis following arthroscopic femoroacetabular impingement correction and labral preservation surgery

PURPOSE

The purposes of this study were to (1) evaluate the effect of age on clinical outcomes of arthroscopic femoroacetabular impingement (FAI) with labral preservation surgery and (2) identify predictors of poor postoperative clinical outcomes.

METHODS

Eighty-four patients who underwent hip arthroscopic treatment for FAI between 2009 and 2013 were retrospectively reviewed. Patients were divided into three groups based on age. The Advanced age group consisted of patients over 70 years old, the Middle age group consisted of patients in their 50s and 60s, and the Younger age group consisted of patients less than 50 years of age. Total hip arthroplasty (THA) conversion, radiographic progression of osteoarthritis and patient-reported outcomes including modified Harris Hip Score (MHHS) and Non-arthritic Hip Score (NAHS) were investigated.

RESULTS

The mean follow-up period was 32.2 (range 24-60) months. THA was required in 3 patients in their 50s and 60s, which was a significantly higher rate compared to that in patients Younger than 50 years old (17% vs 0%, p = 0.036). Progression to osteoarthritis was also significantly more frequent in patients in their 50s and 60s than in patients in their 70s (50s and 60s: 33%; 70s: 0%, p = 0.030). In all age groups, the preoperative MHHS and NAHS improved at last follow-up (p < 0.001). The 50s and 60s age group [hazard ratio (HR) 6.62], preoperative mild osteoarthritic change (Tönnis grade 1, HR: 3.29) and severe cartilage damage on the acetabulum (HR: 2.63) were risk factors for progressive osteoarthritis and THA conversion.

CONCLUSIONS

Arthroscopic FAI correction and labral preservation surgery provide favourable clinical outcomes for patients over 70 years old in the absence of significant osteoarthritis and severe acetabular chondral damage. Patients in their 50s and 60s have a higher risk of both THA conversion and progressive osteoarthritis, while patients aged over 70 years show no evidence of progressive osteoarthritis. Chronologic age in isolation is not an absolute contra-indication to hip arthroscopy.

LEVEL OF EVIDENCE

III.

Outcome Trends After Hip Arthroscopy for Femoroacetabular Impingement: When Do Patients Improve?

PURPOSE

To determine when patients reach critical thresholds of clinical improvement after hip arthroscopy for femoroacetabular impingement (FAI) using previously defined cutoffs for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) and to identify risk factors for prolonged recovery.

METHODS

Consecutive patients with a diagnosis of FAI who underwent unilateral hip arthroscopy between January 2010 and January 2015 with at least 2 years of clinical follow-up were studied. The modified Harris Hip Score was collected prospectively at 6 consecutive time points. The number of patients reaching the MCID and PASS at each time point was determined.

RESULTS

During the study period, 340 consecutive hip arthroscopies were performed in 316 patients with a mean final follow-up period of 50 months (range, 29-84 months). The mean modified Harris Hip Score and percentage of patients reaching the MCID and PASS increased at each time point. At 2 years, 271 patients (93%) surpassed the MCID and 212 patients (73%) achieved the PASS. Female sex, age of 40 years or older, and body mass index of 30 or greater were associated with lower rates of achieving the MCID and PASS at set time points. Patients undergoing labral repair had superior PASS rates at 3 months and beyond than patients undergoing labral debridement alone. Patients who did not achieve the PASS by 3 months were more likely to require reoperation.

CONCLUSIONS

Hip arthroscopy for FAI results in increased patient-reported outcome measures at interval follow-up. Most patients reach critical thresholds of minimal and satisfactory clinical improvement. Patients who are female, older, or obese or who undergo labral debridement alone are less likely to reach these milestones at major time intervals. Patients who do not reach the PASS by 3 months are more likely to require reoperation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Diabetic hip arthropathy is associated with a higher prevalence of femoral head chondromalacia: a case-controlled study

INTRODUCTION

No previous studies have characterised hip joint disease in diabetic patients undergoing hip arthroscopy. The purpose of our study was to evaluate intra-articular hip pathology and surgical variables in patients with diabetes compared to matched, non-diabetic controls. We hypothesised that diabetic patients would demonstrate a higher prevalence and severity of hip chondral pathology.

METHODS

We retrospectively reviewed 795 consecutive hip arthroscopies performed by a single surgeon between 2010 and 2015. Patients ⩾18 years of age without a history of diabetes served as controls and were matched based on age, sex, body mass index, duration of symptoms, and operative side. Clinical symptoms, preoperative physical examination, and radiologic and intraoperative findings were assessed. The primary outcomes were the acetabular and femoral head chondromalacia index (CMI), calculated as the product of the Outerbridge chondromalacia grade and surface area (mm²*severity).

RESULTS

15 diabetic patients were matched to 137 non-diabetic controls. Diabetic patients demonstrated a higher prevalence of femoral head chondromalacia compared to controls both on magnetic resonance imaging (45.5% vs. 7.5%, p = 0.002) and during arthroscopy (100% vs. 75.9%, p = 0.042). Femoral head chondromalacia in diabetic patients had higher Outerbridge grade (2.4 vs. 2.0, p = 0.030) but similar CMI (513.0 vs. 416.4, p = 0.298) compared to controls.

DISCUSSION

Femoral head chondral pathology was more prevalent and of higher severity grade in diabetic patients. The prevalence, size, and severity of acetabular chondral disease were similar between diabetic and non-diabetic patients. Multivariate analysis demonstrated that diabetic status was independently associated with the presence of femoral head chondromalacia.

Is hip muscle strength normalised in patients with femoroacetabular impingement syndrome one year after surgery?: Results from the HAFAI cohort

OBJECTIVES

Little is known about hip function after hip arthroscopic surgery in patients with femoroacetabular impingement syndrome. Hence, the aim of the study was (1) to investigate changes in hip muscle strength from before to one year after hip arthroscopic surgery, (2) to compare patients with a reference group.

DESIGN

Cohort study with a cross-sectional comparison.

METHODS

Before and after hip arthroscopic surgery, patients underwent hip muscle strength testing of their hip flexors and extensors during concentric, isometric and eccentric contraction in an isokinetic dynamometer. Reference persons with no hip problems underwent tests at a single time point. Participants completed completed the Copenhagen Hip and Groin Outcome Score (HAGOS) questionnaire and physical capacity (stair climbing loaded and unloaded, stepping loaded and unloaded and jumping) tests.

RESULTS

After surgery, hip flexion strength improved during all tests (6-13%, p<0.01) and concentric hip extension strength improved (4%, p=0.002). Hip flexion and extension strength was lower for patients than for reference persons (9-13%, p<0.05) one year after surgery. Higher hip extension strength after surgery was associated with better patient reported outcomes. Patients, who were unable to complete at minimum one test of physical capacity, demonstrated significantly weaker hip muscle strength. Compared with their healthy counterparts, female patients were more impaired than male patients.

CONCLUSIONS

One year after surgery, patients improved their maximal hip muscle strength. When compared to reference persons, maximal hip muscle strength was still impaired.

A systematic review-meta-analysis of venous thromboembolic events following primary hip arthroscopy for FAI: clinical and epidemiologic considerations

The purpose of this study was to report the proportion of venous thromboembolic events (VTE) in patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) and present a critical overview of the literature to aid in better result interpretation. MedLine, Scopus and Web of Science databases were searched from January 2000 to March 2017. Four thousand-five-hundred and seventy-seven hip cases were included in the meta-analysis of 38 studies. The mean age of patients was 36 ± 1.8 years and the mean follow-up time was 20.6 months. The meta-analysed rate of deep vein thrombosis (DVT) in patients undergoing primary hip arthroscopy for FAI syndrome was 1.18%; 95%CI [0.8–1.74%]; The meta-analysed rate of pulmonary embolism (PE) in patients undergoing primary hip arthroscopy for FAI syndrome was 0.59%; 95%CI [0.38–0.92%]. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria the Quality in Prognostic Studies (QUIPS) tool. Sensitivity analysis was conducted to assess for publication bias and its influence on the results. The corrected for publication bias proportion of DVT was 2.02%; 95%CI [1.36–2.99%]. The DVT rate was double following the correction of bias while additional types of bias were detected. Attention must be paid when considering the outcomes of observational studies to make clinical decisions. Insufficient evidence exists to support whether anti-VTE chemoprophylaxis should be administered to patients undergoing primary hip arthroscopy for FAI. Due to the life-threatening character of this complication, the results should serve as starting point to design clinical trials and establish guidelines. Until then, the application of preventive measures against VTE should be decided on a case-by-case basis.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Excision of Labral Amorphous Calcification as a Part of Hip Arthroscopy-Clinical Outcomes in a Matched-Controlled Study

PURPOSE

To evaluate clinical outcomes, demographics, and radiographic findings for patients whose hip arthroscopies involved amorphous calcification (AC) excision and to compare them with a control group with no AC and with the general population regarding diabetes mellitus and hypothyroidism.

METHODS

Patients who underwent primary hip arthroscopy involving surgical excision of AC deposit in the anterosuperior labralcapsular recess between October 2008 and July 2014 were reviewed. Demographics, radiographic findings, intraoperative findings, and procedures were reviewed. Minimum follow-up was 2 years and included visual analog scale for pain, patient satisfaction, and the following patient-reported outcome scores: modified Harris hip score, hip outcomes score sport-specific subscale, and nonarthritic hip score. These patients were matched (1:2 ratio) to patients who underwent hip arthroscopy with no AC using the following matching criteria: age at surgery ± 5 years, body mass index ± 5, gender, type of labral treatment, and type of capsular treatment.

RESULTS

We reviewed 12 cases in 11 female patients. Mean latest follow-up scores improved from 64.0 to 83.4 (P = .003) for modified Harris hip score, from 57.6 to 80.6 (P < .001) for nonarthritic hip score, from 35.4 to 62.7 (P = .021) for hip outcomes score sport-specific subscale, and from 6.4 to 2.8 (P = .016) for visual analog scale. The survivorship rate was 91.7%, with one hip converting to total hip arthroplasty. Mean patient satisfaction was 8.4 ± 2.3. Six hips of the 12 (50%) had clock face localization of the AC. They were all between 11 and 12 with a mean of 12:30. Postoperative radiographic findings showed no subsequent AC in all 12 hips. No complications or revisions were reported. There were no significant differences between the AC group and the control group.

CONCLUSIONS

The treatment of AC as part of hip arthroscopy for labral tear and femoro-acetabular impingement is safe and has favorable and similar outcomes compared with a control group at minimum 2-year follow-up. Female gender may be a risk factor for the development of AC. There is no strong evidence that AC should be debrided.

LEVEL OF EVIDENCE

Level III, case control study.

Independent Risk Factors for Revision Surgery or Conversion to Total Hip Arthroplasty After Hip Arthroscopy: A Review of a Large Statewide Database From 2011 to 2012

PURPOSE

To use a large heterogeneous population to identify independent risk factors for revision surgery or conversion to total hip arthroplasty (THA) after hip arthroscopy.

METHODS

The New York Statewide Planning and Research Cooperative System database was queried from 2011 through 2012 to identify patients undergoing hip arthroscopy. All patients aged 18 years or older who underwent hip arthroscopy according to Current Procedural Terminology coding were included. We chose to divide surgical volume into tertiles for the purposes of statistical analysis. Longitudinal analysis for a minimum of 2 years was performed to determine risk factors for revision surgery or conversion to THA.

RESULTS

We identified 3,957 patients. The mean age was 35.8 years (standard deviation, 13.1 years). After a minimum follow-up period of 2 years, the overall failure rate was 9.6%: 3.7% of patients underwent revision hip arthroscopy at an average of 15.8 months, whereas 5.9% underwent conversion to THA at 14.7 months. Index surgery performed by surgeons in the third tertile of surgical volume (<40 cases per annum) was an independent risk factor for revision (odds ratio [OR], 1.71; P = .001), as well as conversion to THA (OR, 1.90; P < .001). Female patients (OR, 1.8; P < .001), older patients (OR, 3.4; P < .001), and patients with a history of obesity (OR, 5.6; P < .001) underwent conversion to THA at significantly higher rates than other patients. Young patients (OR, 4.4; P < .001) and female patients (OR, 1.6; P < .001) were more likely to undergo revision hip arthroscopy.

CONCLUSIONS

Our analysis of 3,957 patients found that female sex, age under 40 years, absence of a labral repair, and index procedure performed by a low-volume surgeon were independent risk factors for revision hip arthroscopy. Age over 60 years, index procedure performed by a low-volume surgeon, female sex, obesity, and the presence of pre-existing arthritis were risk factors for THA conversion.

LEVEL OF EVIDENCE

Level III, case-control study.

Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review

PURPOSE

The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria.

RESULTS

Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives.

CONCLUSIONS

The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Outcomes of Hip Arthroscopy in the Older Adult: A Systematic Review of the Literature

BACKGROUND

The indications for hip preservation surgery have expanded to include treatment of hip pathology in older adults. While several studies have examined the efficacy of hip arthroscopy in the setting of osteoarthritis, there has been no review of outcomes in older adults.

PURPOSE

To review the outcomes of hip arthroscopy in older adults and identify factors associated with treatment failures.

STUDY DESIGN

Systematic review.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched through March 2016 for studies reporting outcomes of primary hip arthroscopy in patients older than 40 years. Inclusion in the review was based on age, patient-reported outcome (PRO) measures, and duration of follow-up. Two authors screened the results and extracted data for use in this review. Standardized mean difference was calculated to estimate effect size for PRO scores within studies.

RESULTS

Eight studies with 401 total patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) or labral tears were included in this review. Seven of the 8 studies reported favorable PRO scores and significant postoperative improvement with moderate to large effect size. The included studies demonstrated a trend toward higher effect sizes with an increasing percentage of labral repair compared to isolated labral debridement. The complication rate was comparable to that of previous reports involving younger patients; however, the overall reoperation rate was 20.8%. Conversion to hip arthroplasty ranged from 0% to 30%, with an overall conversion rate of 18.5% at a mean time of 17.5 months following arthroscopy. The most common risk factors for conversion to arthroplasty were low preoperative PRO scores and advanced arthritis.

CONCLUSION

Hip arthroscopy appears to be a safe and efficacious treatment for labral tears and FAI in older patients who do not have significant underlying degenerative changes. However, in this population, there is a significant proportion of patients who eventually require hip arthroplasty. Outcomes may be affected by type of treatment (ie, labral debridement vs repair). Additional high-quality studies are needed to understand how these factors affect outcomes.

Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review

PURPOSE

To (1) report clinical outcomes, complication rates, and total hip arthroplasty (THA) conversion rates for patients age 40 or older who underwent hip arthroscopy, and (2) report any age-related predictors of outcome identified in the literature.

METHODS

MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data were abstracted from eligible studies. No meta-analysis was performed because of heterogeneity amongst studies.

RESULTS

Seventeen studies were included in this review comprising 16,327 patients, including 9,954 patients age 40 or older. All studies reported statistically significant improvements in outcomes after hip arthroscopy for femoral osteochondroplasty, labral repair, or unspecified indications. In patients 40 or older who underwent labral debridement, these improvements were not clinically significant. Obesity and osteoarthritic changes predicted poorer outcomes. Only 1 of 3 studies directly comparing the 2 groups found that patients 40 or older had a significantly less improvement in a standardized hip outcome score than patients under 40 after hip arthroscopy, but all found that patients 40 or older had significantly higher rates of THA conversion. The rate of conversion to THA was 18.1% for patients 40 or older, 23.1% for patients over 50, and 25.2% for patients over 60 with a mean of 25.0 months to THA.

CONCLUSIONS

Indications for hip arthroscopy including femoral osteochondroplasty and labral repair resulted in clinically significant improvements in patients 40 or older in most research studies examined in this review, whereas labral debridement did not produce clinically significant improvements postoperatively in the same studies. In these studies, the rate of conversion to THA is higher than in patients under 40 and increases with each decade of life, with many individual studies showing a significant increase in the rate of THA conversion. Hip arthroscopy may be suitable for some patients 40 or older, but patient selection is key and patients should be informed of the higher risk of conversion to THA.

LEVEL OF EVIDENCE

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

Clinical results of arthroscopic surgery in patients over 50 years of age-what viability does it have as a joint preservative surgery?

BACKGROUND

To identify whether hip arthroscopy is a suitable option for treating hip pain in elderly patients and investigate the clinical outcomes of hip arthroscopic surgery for labrum tear and/or osteoarthritis in patients over 50 years of age.

METHODS

Between August 2009 and May 2014, a series of 23 patients (6 men and 17 women) with a mean age of 59 years underwent arthroscopy. We retrospectively examined the clinical records, radiographs, and outcome questionnaires from all patients. The mean follow-up period was 28 months.

RESULTS

The mean Japan Orthopedic Association hip score after surgery improved by a statistically significant amount. Eight patients (34.8%) were noted to have a progression of osteoarthritis (OA) diagnosed by radiograph, and one underwent THA after 13 months following arthroscopic surgery. The patients in which OA progression was noted were identified as having radiographical OA preoperatively and acetabular cartilage damage in the arthroscopic findings.

CONCLUSIONS

Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings.

Clinical Outcomes of Hip Arthroscopy in Patients 60 or Older: A Minimum of 2-Year Follow-up

PURPOSE

To examine clinical outcomes and survivorship in patients aged 60 years or older who underwent hip arthroscopy for management of hip pain.

METHODS

Prospectively collected data for patients 60 or older undergoing hip arthroscopy were obtained. All patients were indicated for hip arthroscopy based on standard preoperative examination as well as routine and advanced imaging. Demographic data, diagnosis, and details regarding operative procedures were collected. Baseline preoperative modified Harris Hip Scores (mHHS) and Non-arthritic Hip Scores (NAHS) were compared to mHHS and NAHS at the 2-year follow-up. Survivorship was assessed to determine failure rates, with failure defined as any subsequent ipsilateral revision arthroscopic surgery and/or hip arthroplasty.

RESULTS

Forty-two patients met inclusion criteria. Mean age (standard deviation) and body mass index were 65.8 years (4.5 years) and 26.1 (4.7), respectively. Baseline mean mHHS and NAHS for all patients improved from 47.8 (±12.5) and 47.3 (±13.6) to 75.6 (±17.6) and 78.3 (±18.6), respectively (P < .001 for both). Five patients (11.9%) met failure criteria and underwent additional surgery at an average of 14.8 (8-30) months. Three underwent conversion to total hip arthroplasty (7.1%), whereas 2 had revision arthroscopy with cam/pincer resection and labral repair for recurrent symptoms (4.7%). One- and 2-year survival rates were 95.2% and 88.9%, respectively.

CONCLUSIONS

Our results suggest that in patients 60 or older with Tonnis grade 0 or 1 osteoarthritic changes on initial radiographs-treatment with hip arthroscopy can lead to reliable improvement in early outcomes. As use of hip arthroscopy for treatment of mechanical hip pain increases, additional studies with long-term follow-up are needed.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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

AIM

To investigate pain, activities of daily living (ADL) function, sport function, quality of life and satisfaction at different time points after hip arthroscopy in patients with femoroacetabular impingement (FAI).

DESIGN

Systematic review with meta-analysis. Weighted mean differences between preoperative and postoperative outcomes were calculated and used for meta-analysis.

DATA SOURCES

EMBASE, MEDLINE, SportsDiscus, CINAHL, Cochrane Library, and PEDro.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies that evaluated hip pain, ADL function, sport function and quality of life before and after hip arthroscopy and postoperative satisfaction in patients with symptomatic FAI.

RESULTS

Twenty-six studies (22 case series, 3 cohort studies, 1 randomised controlled trial (RCT)) were included in the systematic review and 19 in the meta-analysis. Clinically relevant pain and ADL function improvements were first reported between 3 and 6 months, and sport function improvements between 6 months and 1 year after surgery. It is not clear when quality of life improvements were first achieved. On average, residual mild pain and ADL and sport function scores lower than their healthy counterparts were reported by patients following surgery. Postoperative patient satisfaction ranged from 68% to 100%.

CONCLUSIONS

On average, patients reported earlier pain and ADL function improvements, and slower sport function improvements after hip arthroscopy for FAI. However, average scores from patients indicate residual mild hip pain and/or hip function lower than their healthy counterparts after surgery. Owing to the current low level of evidence, future RCTs and cohort studies should investigate the effectiveness of hip arthroscopy in patients with FAI.

TRIAL REGISTRATION NUMBER

CRD42015019649.

The incidence of deep vein thrombosis (DVT) during hip arthroscopic surgery

INTRODUCTION

The use of hip arthroscopy has been widely increasing. Although deep vein thrombosis (DVT) is thought to be a serious complication of orthopaedic surgery, there were few reports discussing DVT related to hip arthroscopic surgery. This study aimed to investigate the incidence and risk factors of DVT related to hip arthroscopic surgery.

MATERIALS AND METHODS

This retrospective study included 72 patients. Clinical diagnosis of DVT was confirmed through ultrasonography performed preoperatively and 3 days postoperatively. Additionally, D-dimer levels were measured preoperatively and on postoperative days 1, 3, and 7. Age, body mass index, operation time, procedure type, and D-dimer levels were statistically compared between the two groups (identified DVT vs. no identified DVT).

RESULTS

Five patients (6.94 %) were diagnosed with DVT clinically, although all cases were asymptomatic. The mean age of the patients with identified DVT was 62.0 ± 6.1 years; significantly higher than the mean age of the patients without DVT (45.1 ± 1.7 years; P = 0.0188).

CONCLUSION

The incidence of DVT during hip arthroscopy, investigated by ultrasound, was 6.94 %. From our results, we recommend screening for and treatment of asymptomatic DVT, especially in older patients, during hip arthroscopic surgery.

Are Short-term Outcomes of Hip Arthroscopy in Patients 55 Years and Older Inferior to Those in Younger Patients?

BACKGROUND

Hip arthroscopy for young patients with femoroacetabular impingement (FAI) has been successful, but the efficacy of hip arthroscopy in older patients is not clearly defined.

PURPOSE

To evaluate the clinical outcomes of patients 55 years and older who are undergoing hip arthroscopy and to compare outcomes with those of patients younger than 55 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A total of 201 (63 male, 138 female) patients undergoing primary hip arthroscopy for FAI without radiographic arthritis (Tönnis grade <3) were isolated from a prospective database and stratified by age to <55-year and ≥55-year groups. Patients were evaluated preoperatively and 1 and 2 years postoperatively using the modified Harris Hip Score (mHHS) and Hip Outcome Score (HOS: functional scores, as well as Activities of Daily Living [ADL] and Sport subscales). A Wilcoxon signed rank sum test was used to evaluate the differences in outcome scores between the cohorts at each interval.

RESULTS

The <55-year group included 174 patients (mean age, 37 ± 12 years), and the ≥55-year group included 27 patients (mean age, 61 ± 5 years). The minimum follow-up time was 2 years in each group. Preoperative Tönnis grades and mHHS scores (59 vs 59; P = .75) were similar between groups. The ≥55-year cohort underwent labral debridement more frequently (78% vs 36%; P =.02) and were more likely to have full-thickness cartilage defects (22% vs 4%; P = .04). Despite this, the mHHS in both groups improved significantly from baseline, without significant differences at 1 year (86 [≥55 years] vs 81 [<55 years]; P = .53) or 2 years (73.88 [≥55 years] vs 79.54 [<55 years]; P = .06). However, at a minimum 2-year follow-up, patients <55 years had significant improvements over patients ≥55 years in the HOS subscales for ADL score (85.6 vs 75.2; P = .03), ADL rating (80.1 vs 70.0; P = .004), Sport score (70.2 vs 55.6; P = .04), and Sport rating (70.2 vs 58.0; P = .04).

CONCLUSION

Although younger patients had superior HOS outcomes reported at 2 years compared with older patients after hip arthroscopy for FAI, both groups had significant improvement compared with their baseline. These data suggest that carefully selected patients 55 years and older without radiographic arthritis may benefit from hip arthroscopy.

Iliotibial band syndrome following hip arthroscopy: An unreported complication

BACKGROUND

Hip arthroscopy is considered a safe procedure, considering the relatively low rate of complications. Despite several complications have been described following this surgical procedure, the present event has not yet been described. The purpose of the present study is to report an unpublished complication following hip arthroscopy, after reviewing 162 hip arthroscopies and finding iliotibial band syndrome (ITBS) in the knee during followup.

MATERIALS AND METHODS

A retrospective review of 162 hip arthroscopies performed between September 2007 and June 2011 was carried out, evaluating patients who presented ITBS during followup. Indication for hip arthroscopy was failure of conservative treatment in patients with symptomatic femoroacetabular impingement.

RESULTS

During a minimum followup of 2 years, nine patients (5.5%) developed ITBS. All patients were diagnosed with ITBS within the first 45 postoperative days. Conservative treatment was successful in 6 patients while 3 had to undergo surgery. The increased internal rotation, synovitis and increased adduction of the hip can be attributed as predisposing factors to the development of ITBS.

CONCLUSIONS

This is a newly described observation within followup of hip arthroscopy. These findings may help orthopedic surgeons when planning rehabilitation after hip arthroscopy, including stretching exercises to prevent this syndrome.

Osteoarthritic changes rather than age predict outcome following arthroscopic treatment of femoroacetabular impingement in middle-aged patients

BACKGROUND

Our purpose was to evaluate outcome following arthroscopic treatment of femoroacetabular impingement (FAI) in middle-aged patients and to define risk factors for conversion to total hip arthroplasty (THA).

METHODS

This was a retrospective case series of 79 consecutive patients (40 to 65 years) undergoing arthroscopic treatment of FAI (follow-up ≥12 months). Outcome at follow-up was assessed using Hip outcome score (HOS). Alpha angle, Kellgren Lawrence grade (K-L grade), joint space width (JS), lateral center edge (LCE) angle, caput-collum-diaphysis (CCD) angle and acetabular index (AI) were analysed retrospectively. THA group and Non-THA group were compared.

RESULTS

Seventy-nine patients (mean age 48.6 years, mean follow-up 32 months) were included. 18 patients (22.8 %) were converted to THA. Mean HOS score in the Non-THA group at time point of follow-up was 80.2. Non-THA group and THA group showed no significant differences for mean age (48.2 years vs. 49.9 years, p = 0.278), alpha angel (p = 0.541), LCE (p = 0.294), CCD (p = 0.101) and AI (p = 0.661) in contrast to differences for JS (p = <0.001) and K-L grade (p = <0.001). Risk of conversion to THA was higher for patients with K-L grade 3 (p = 0.003) or joint space less or equal 2 mm (p = 0.001).

CONCLUSIONS

One fifth of the middle-aged patients required early conversion to THA. Advanced JS narrowing and K-L grade rather than age alone can be considered as risk factor for conversion to THA.

Hip morphology influences the pattern of articular cartilage damage

PURPOSE

The aim of this study was to obtain data on chondral damage and compare the damage patterns of various hip disorders.

METHODS

Data were collected at 100 consecutive arthroscopies, and chondral lesions were recorded on anatomic articular maps divided into different anatomical zones. This geographic zone method made it possible to analyze the ICRS grade and location in relation to the hip morphology.

RESULTS

The distribution and degree of the chondral defects showed a hip morphology-specific pattern. On the acetabular side, there were high incidences of full-thickness defects in the anterior-superior zone and the middle superior zone in patients with femoroacetabular impingement (FAI) (zone 2: 25.4 % grade 3, 35.5 % grade 4; zone 3: 20.3 % grade 3, 37.2 % grade 4) and borderline dysplasia (zone 2: 31.2 % grade 3, 12.5 % grade 4; zone 3: 18.7 % grade 3, 25 % grade 4). However, in patients with joint laxity, partial-thickness defects were dominant (zone 2: 50 % grade 1, 15 % grade 2; zone 3: 40 % grade 1). In patients with acetabular dysplasia, full-thickness defects extended even to the posterior superior zone (zone 4: 80 % grade 4). On the femoral head side, the incidence of full-thickness cartilage injuries was high in patients with FAI and borderline dysplasia compared to those with joint laxity and acetabular dysplasia.

CONCLUSION

Evaluation of chondral damage using the geographic zone method showed that the pattern of cartilage damage was influenced by hip morphology. Understanding of hip disorder-specific chondral damage patterns may be useful for the development of arthroscopic classification of hip disorders and may lead to the establishment of treatment guidelines.

LEVEL OF EVIDENCE

Diagnostic study, Level III.

Hip arthroscopy for the treatment of femoroacetabular impingement: a comparative study between the classic and the outside-in access

PURPOSE

To compare the functional outcomes of patients undergoing arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) performed with either the classic or the outside-in access to the hip.

METHODS

Data regarding patients arthroscopically treated for FAI from January 2009 to June 2013 were retrospectively reviewed and compared regarding the type of access.

RESULTS

101 hips (91 patients) with a minimum of 12 months follow-up (mean 22 months, range 12-40 months) were included. Classic access was used in 48 cases while outside-in access was performed in 53 cases. Mean age was 37 years (range 15.7-59.6 years). Both groups were comparable with respect to preoperative characteristics. Mean operating time was 162 minutes for the outside-in group and 172 minutes for the classic access group. Complications between both groups showed no statistically significant differences but for the presence of heterotopic calcifications, which was more frequently observed regarding the outside-in access. Outcomes measured by the modified Harris Hip Score showed no overall differences regarding both types of access, except for patients under 35 years old, where there was a statistically significant increase in excellent and good outcomes with the use of the classic access in comparison to the outside-in technique. Postoperative hip motion was also significantly higher in the classic access group.

CONCLUSIONS

No differences have been found in outcomes regardless the access used. Classic access seems to offer a higher postoperative range of motion and lower risk of heterotopic ossifications.

Overdiagnosing of femoroacetabular impingement: correlation between clinical presentation and computed tomography in symptomatic patients

Objective

To correlate the angles between the acetabulum and the proximal femur in symptomatic patients with femoroacetabular impingement (FAI), using computed tomography (CT).

Methods

We retrospectively evaluated 103 hips from 103 patients, using multislice CT to measure the acetabular age, acetabular version (in its supraequatorial portion and in its middle third), femoral neck version, cervical-diaphyseal and alpha angles and the acetabular depth. For the statistical analysis, we used the Pearson correlation coefficient.

Results

There were inverse correlations between the following angles: (1) acetabular coverage versus alpha angle (p = 0.019); (2) acetabular version (supraequatorial) versus alpha angle (p = 0.049). For patients with femoral anteversion lower than 15 degrees: (1) acetabular version (supraequatorial) versus alpha angle (p = 0.026); (2) acetabular version (middle third) versus alpha angle (p = 0.02). For patients with acetabular version (supraequatorial) lower than 10 degrees: (1) acetabular version (supraequatorial) versus alpha angle (p = 0.004); (2) acetabular version (middle third) versus alpha angle (p = 0.009).

Conclusion

There was a statistically significant inverse correlation between the acetabular version and alpha angles (the smaller the acetabular anteversion angle was, the larger the alpha angle was) in symptomatic patients, thus supporting the hypothesis that FAI occurs when cam and pincer findings due to acetabular retroversion are seen simultaneously, and that the latter alone does not cause FAI, which leads to overdiagnosis in these cases.

The 2015 Frank Stinchfield Award: Radiographic Abnormalities Common in Senior Athletes With Well-functioning Hips but Not Associated With Osteoarthritis

BACKGROUND

It is not known whether morphological abnormalities of the hip are compatible with lifelong hip function and avoidance of osteoarthritis (OA). Our purpose was to investigate the prevalence of radiographic findings consistent with femoroacetabular impingement (FAI) and dysplasia (DDH) in senior athletes with well-functioning hips.

QUESTIONS/PURPOSES

(1) What is the prevalence of FAI and DDH in senior athletes with well-functioning hips? (2) Are radiographic findings of FAI and DDH associated with OA? (3) Is a history of longer duration or more intense activity associated with hip pathomorphology? (4) Were the modified Harris hip scores and the Hip Outcome Scores lower (legacy scales) in patients with evidence of hip pathomorphology than those without?

METHODS

Five hundred forty-seven individuals (55% men, 45% women; 1081 hips, 534 bilateral and 13 unilateral), mean age 67 years (SD 8 years), gave consent and qualified for this institutional review board-approved cross-sectional study of senior athletes. Hips were independently evaluated for radiographic signs of FAI, DDH, and OA. Additionally, a lifetime activities questionnaire and outcome instruments were used to assess pain and function. Hips that had previously undergone arthroplasty or fracture surgery were excluded.

RESULTS

Eighty-three percent (898 of 1081) of hips had radiographic abnormalities consistent with FAI, of which 67% (599 of 898) were cam-type FAI. Ten percent (103 of 1081) of hips had radiographic evidence for dysplasia. Radiographic findings of FAI were not predictive of OA after controlling for age and sex (odds ratio [OR], 1.79; 95% confidence interval [CI], 0.48-6.62; p = 0.390). Similarly, radiographic findings of DDH were not predictive of OA (OR, 1.48; 95% CI, 0.31-7.21; p = 0.62). Our data suggest an increased risk of FAI-type morphologies in athletes who participated in competitive sporting events during early adult years (OR, 1.49; 95% CI, 1.04-2.11; p = 0.020). Additionally, participants who reported lifetime participation in competitive sports were at an increased risk of OA compared with those who did not (OR, 1.75; 95% CI, 1.14-2.69; p = 0.007). There were no differences in outcome scores between athletes with and without morphologic abnormalities.

CONCLUSIONS

Radiographic findings consistent with FAI in these senior athletes were common and were not associated with the presence of OA. These data suggest that the need to screen for asymptomatic young athletes for radiographic evidence of FAI and DDH may not be necessary.

LEVEL OF EVIDENCE

Level III, prognostic study.

Clinical and Radiographic Predictors for Worsened Clinical Outcomes After Hip Arthroscopic Labral Preservation and Capsular Closure in Developmental Dysplasia of the Hip

BACKGROUND

Patients with developmental dysplasia of the hip (DDH) have a greater risk of acetabular labral tearing and joint instability, which predispose them to developing osteoarthritis. The arthroscopic management of DDH, however, remains controversial.

HYPOTHESIS

Specific clinical characteristics and radiographic parameters correlate with and predict a worsened clinical outcome after hip arthroscopic surgery for DDH.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Of patients with DDH who underwent an arthroscopic procedure between March 2009 and June 2011, there were 28 hips in 28 patients (6 male and 22 female) that met the inclusion criteria. The mean patient age was 28.4 years. Clinical and radiographic follow-up evaluations up to a minimum of 2 years after surgery were performed for all patients. Failure of the procedure was defined as conversion to subsequent surgery or having a Tönnis osteoarthritis grade of 2 and modified Harris Hip Score (mHHS) that remained <85, and success was defined as patients who did not need subsequent surgery and had an mHHS >85. Univariate analysis and Cox hazard proportional analysis were performed on the 2 subpopulations.

RESULTS

There were 9 patients in the failure group (including 3 hips with T nnis grade 2) and 19 patients in the success group. In 22 of 28 patients, the mean mHHS significantly improved from 61.6 ± 18.8 (range, 12.0-85.0) preoperatively to 94.3 ± 7.0 (range, 73.7-100.0) at final follow-up, and the mean Non-Arthritic Hip Score (NAHS) improved from 56.2 ± 13.9 (range, 35.0-81.3) preoperatively to 92.7 ± 9.5 (range, 65.0-100.0) at final follow-up (P < .001, Wilcoxon signed-rank test). Univariate analysis showed that a broken Shenton line was significantly more prevalent in the failure group compared with the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). High-grade cartilage delamination (Multicenter Arthroscopy of the Hip Outcomes Research Network [MAHORN] grades 3-5) was significantly higher in the failure group than in the success group (8/9 [89%] vs 3/19 [16%] patients, respectively; P < .001). The median femoral neck-shaft (FNS) angle in the failure group was significantly higher than that in the success group (139° vs 134°, respectively; P = .01). Further, Cox hazard proportional analysis of the failure group showed that the predictors for a poor clinical outcome were the presence of a broken Shenton line, FNS angle >140°, center-edge (CE) angle <19°, body mass index (BMI) >23 kg/m(2), acetabular cartilage damage (MAHORN grades 3-5), and cartilage damage of the femoral head (International Cartilage Repair Society grades 2-4). The most important predictors for a poor clinical outcome at the time of surgery were a broken Shenton line and an FNS angle >140°.

CONCLUSION

Patients with a broken Shenton line, FNS angle >140°, CE angle <19°, or BMI >23 kg/m(2) at the time of surgery are not good candidates for the arthroscopic management of DDH.

Dislocation After Hip Arthroscopy for Cam-Type Femoroacetabular Impingement Leading to Progressive Arthritis: A Case Report

CASE

We present the case of a fifty-two-year-old man who underwent hip arthroscopy for cam-type femoroacetabular impingement and had an anterior hip dislocation three weeks postoperatively. The patient did not have any of the previously identified risk factors for instability after hip arthroscopy. He underwent revision involving capsular repair and removal of loose bodies but progressed to needing total hip arthroplasty within two years.

CONCLUSION

This case illustrates that even patients without the previously reported risk factors for hip instability are at risk of dislocation after hip arthroscopy and this can lead to rapid joint degeneration necessitating arthroplasty.

Femoroacetabular Impingement: Prevalent and Often Asymptomatic in Older Men: The Osteoporotic Fractures in Men Study

BACKGROUND

The epidemiology of femoroacetabular impingement (FAI) is important but incompletely understood, because most reports arise from symptomatic populations. Investigating the prevalence of FAI in a community-based cohort could help us better understand its epidemiology and in particular the degree to which it might or might not be associated with hip pain.

QUESTIONS/PURPOSES

The purposes of this study were (1) to evaluate the proportion of older (≥65 years of age) men with morphologic abnormalities consistent with FAI; and (2) to assess the association of the morphologic abnormalities with prevalent radiographic hip osteoarthritis (OA) and hip pain.

METHODS

Anteroposterior radiographs were obtained in 4140 subjects (mean age±SD, 77±5 years) from the Osteoporotic Fractures in Men study. We assessed each hip for cam, pincer, and mixed FAI types using validated radiographic definitions. Both intra- and interobserver reproducibility were >0.9. Radiographic hip OA was assessed by an expert reader (intraobserver reproducibility, 0.7-0.8) using validated methods, and summary grades of 2 or greater (on a scale from 0 to 4) were used to define radiographic hip OA. Covariates including hip pain in the last 30 days were collected by questionnaires that were answered by all patients included in this report. Logistic regressions with generalized estimating equations were performed to evaluate the association of radiographic features of FAI and arthrosis.

RESULTS

Pincer, cam, or mixed types of radiographic FAI had a prevalence of 57% (1748 of 3053), 29% (886 of 3053), and 14% (419 of 3053), respectively, in this group of older men. Both pincer and mixed types of FAI were associated with arthrosis but not with hip pain (odds ratio [OR], 1.63; 95% confidence interval [CI], 1.25-2.13; p<0.001 for pincer and OR, 2.49; 95% CI, 1.65-3.76; p<0.001 for mixed type). Patients with hips characterized by cam-type FAI had slightly reduced hip pain without the presence of arthrosis compared with hips without FAI (OR, 0.82; 95% CI, 0.68-0.99; p=0.037). A center-edge angle>39° and a caput-collum-diaphyseal angle<125° were associated with arthrosis (OR, 1.53; 95% CI, 1.22-1.94; p<0.001 and OR, 2.09; 95% CI, 1.24-3.51; p=0.006, respectively), but not with hip pain (OR, 0.89; 95% CI, 0.77-1.03; p<0.108 and OR, 0.99; 95% CI, 0.67-1.45; p=0.945, respectively). An impingement angle<70° was associated with less hip pain compared with hips with an impingement angle≥70° (OR, 0.76; 95% CI, 0.61-0.95; p=0.015).

CONCLUSIONS

FAI is common in older men and represents more of an anatomic variant rather than a symptomatic disease. This finding should raise questions on how age, activities, and this anatomic variant each contribute to result in symptomatic disease.

LEVEL OF EVIDENCE

Level III, prognostic study.

Reporting of non-hip score outcomes following femoroacetabular impingement surgery: a systematic review

This systematic review was designed to evaluate the reporting of non-hip score outcomes following surgical management of femoroacetabular impingement (FAI). MEDLINE, EMBASE and PubMed were searched and screened in duplicate for studies involving non-hip score outcomes following the surgical management of FAI. A full-text review of eligible studies was conducted and references were searched using pre-determined inclusion and exclusion criteria. Thirty-three studies involving 3198 patients were included in this review. The most common non-hip score outcomes reported included: patient satisfaction (72.7%), symptom improvement (24.7%), pain improvement (12.4%), hip range of motion (12.3%) and return to sport (6.8%). The most frequently reported standardized hip outcome scores used were the modified Harris Hip Score (mHHS) (41.2%), Non-Arthritic Hip Score (NAHS) (29.4%), Hip Outcome Score—Activities of Daily Living (HOS-ADL) (26.5%), the Western Ontario McMaster Universities Index of Osteoarthritis (WOMAC) (17.6%), the HOS Sport-Specific Subscale (SSS) (17.6%). The most commonly reported non-hip score outcomes are patient satisfaction, symptom improvement and pain improvement. Patients report high levels of satisfaction when surveyed post-operatively. A discrepancy exists between what outcomes the literature suggests should be reported and what outcomes are actually reported. Return to sport is often held as a major patient-important outcome yet it is seldom reported in studies assessing the efficacy of FAI surgery. Second, despite emerging evidence that outcome measures such as the HOS or IHOT evaluate the FAI patient population precisely, other standardized hip score outcomes (mHHS and NAHS) are still more commonly reported.

The effect of platelet enriched plasma on clinical outcomes in patients with femoroacetabular impingement following arthroscopic labral repair and femoral neck osteoplasty

To compare the clinical outcome of patients treated with and without platelet-rich plasma (PRP) injection while undergoing arthroscopic labral repair and femoral neck osteoplasty for femoral acetabular impingement. Patients were randomized at the time of surgery to receive either an intra-articular injection of 5 cc of PRP, or an equal volume of 0.9% normal saline. All patients underwent arthroscopic labral repair and osteoplasty of the femoral neck and, at the conclusion of the case, received the injection. One week following surgery, thigh circumference (measured 10 cm distal to the tip of the greater trochanter) and the presence of ecchymosis of the thigh were recorded. Clinical outcome scores, including Non-Arthritic Hip Score, Modified Harris Hip Score and Hip Outcome Score were collected prior to surgery at 1, 3, 6 and a minimum of 12 months post-operatively. Thirty-five patients were enrolled into this study. Twenty patients received a PRP injection and 15 received a saline injection. Thigh circumference was compared pre-operatively and 1 week post-operatively. There was no significant difference between the two groups. Ecchymosis was compared between the two groups at 1 week post-operatively. Four of the 20 patients in the PRP group and 10 of the 15 in the placebo group demonstrated bruising on the lateral thigh. This was compared with a Chi-Square test and found to be statistically significant (P = 0.005). There was no significant difference in any of the outcome scores between the two groups. An intra-articular injection of PRP after labral repair did not improve the clinical outcome up to 1 year post-operatively in patients undergoing arthroscopic labral repair and osteoplasty of the femoral neck. Level of evidence is level I study.

Ultrasonography can quantify the extent of osteochondroplasty after treatment of Cam-type femoroacetabular impingement

PURPOSE

Surgical resection of femoroacetabular Cam impingement (cam-FAI) is now a generally accepted treatment, producing adequate hip score increases. Insufficient resection at the head-neck junction is the main reason for revision. The anterolateral region of the head-neck junction is visualized only suboptimally by radiography, which can be inadequate for monitoring resection results postoperatively. Our aim was to investigate the extent of Cam resection by ultrasonography (US) and determine if there is any correlation with clinical outcome.

METHODS

Altogether, 40 consecutive patients (mean age 39 years) were enrolled in this prospective study following arthroscopic Cam resection. All patients underwent standardized US examination in the ventral longitudinal section at 20° external rotation, neutral position, and 20° internal rotation the day before arthroscopy and two days afterward. Alpha angle, anterior offset, offset ratio, and anterior femoral distance were measured on sonograms. Hip Disability and Osteoarthritis Outcome Score (HOOS) and Western Ontario and McMaster University Index of Osteoarthritis (WOMAC) were conducted the day before surgery and 6 weeks postoperatively (at the earliest).

RESULTS

Alpha angle was significantly smaller on postoperative US in all hip joint positions. At 20° internal rotation, the alpha angle decreased from 65.6 to 36.9° (p < 0.0001). All but two (5%) patients had alpha angles <50°. Anterior offset increased significantly on US in neutral position and at 20° internal rotation. HOOS and WOMAC increased significantly. No correlation was found between measurements for Cam-FAI and the scores.

CONCLUSIONS

US may be a useful tool for monitoring Cam-FAI resection results postoperatively.

Outcomes of hip arthroscopy in patients aged 50 years or older compared with a matched-pair control of patients aged 30 years or younger

PURPOSE

Age has been suggested as a negative prognostic factor for hip arthroscopy. The purpose of this study was to compare patient characteristics and outcomes after hip arthroscopy in patients aged 50 years or older with a matched control group of patients aged 30 years or younger at a minimum postoperative follow-up of 2 years.

METHODS

Between September 2008 and March 2010, data were prospectively collected on all patients aged 50 years or older undergoing primary hip arthroscopy. Fifty-two patients met our inclusion and matching criteria, of whom all 52 (100%) were available for follow-up at a minimum of 2 years. This cohort was compared with a matched-pair control group of patients aged 30 years or younger who underwent similar procedures.

RESULTS

The mean age of the study group was 54.8 years (range, 50 to 69 years), and that of the control group was 20.3 years (range, 13 to 30 years). The groups were matched at a 1:1 ratio, including 18 male patients (34.6%) and 34 female patients (65.4%) in each group, with a mean follow-up period of 32 months (range, 24 to 54 months). In the younger control group, the score improvement from preoperatively to 2 years' follow-up was 62.9 to 84.2 for the modified Harris Hip Score, 60.5 to 84.2 for the Non-Arthritic Hip Score, 63.1 to 86.5 for the Hip Outcome Score-Activities of Daily Living, and 42.2 to 72.7 for the Hip Outcome Score-Sport-Specific Subscale. In the older study group, the score improvement from preoperatively to 2 years' follow-up was 61.2 to 82.2 for the modified Harris Hip Score, 59.9 to 80.4 for the Non-Arthritic Hip Score, 63.9 to 83 for the Hip Outcome Score-Activities of Daily Living, and 41.2 to 64.6 for the Hip Outcome Score-Sport-Specific Subscale. All improvements in both groups were statistically significant at the 2-year postoperative follow-up (P < .001). There was no significant difference for all patient-reported outcome (PRO) scores at final follow-up between both groups. When we compared the change in PRO scores (Δ) from preoperatively to 2 years postoperatively, there was no significant difference between both groups. The overall survivorship rate was 98.1% for the younger control group and 82.7% for the older study group.

CONCLUSIONS

Survivors aged 50 years or older show similar improvement to patients aged 30 years or younger in PRO and patient satisfaction scores. The 2-year survivorship rate was 98.1% for the younger control group and 82.7% for the older study group. Therefore we believe that hip arthroscopy should be considered a valid treatment option when treating hip pain in patients aged 50 years or older with a Tönnis arthritic grade of 0 or 1. Older patients should be counseled on the possibility of later conversion to total hip arthroplasty. Future work may include development of a decision-making tool to assess for prognosis to better delineate the indications for hip arthroscopy in the older population.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Outcome of arthroscopy in patients with advanced osteoarthritis of the hip

Hip arthroscopy has continued to expand its horizons in treating many conditions other than femoroacetabular impingement (FAI). However, the results of hip arthroscopy are known to be poor if the degree of articular cartilage damage is significant. We wanted to assess, whether the procedure might have a role in the management of young and active patients with advanced osteoarthritis (OA) and whether it should be offered as a treatment modality. 77 consecutive patients with Tönnis grade 2 and 3 osteoarthritis of the hip who had undergone hip arthroscopy were included in the study. Patients' medical notes, plain radiographs and outcome scores (modified Harris hip score (mHHS), non-arthritic hip score (NAHS)) preoperatively and postoperatively at six weeks, six months, one year and annually thereafter, were analysed. 77 patients consisted of 63 men and 14 women with mean follow-up of 2.8 years (2.2 to 4.2) and mean age at surgery of 43 years (19 to 64). The mean preoperative mHHS and NAHS scores were 58 (28 to 87) and 64 (27 to 93) respectively. The mean improvements in both the mHHS and NAHS scores were significant (p = 0.003 and p = 0.0001 for mHHS at one and two years, p = 0.002 and p = 0.0003 for NAHS at one and two years, respectively). There were 34 patients (44%) who required a total hip replacement at mean of 18 months (6 to 48) after hip arthroscopy. We conclude that hip arthroscopy improves outcome scores in 56% of patients with severe OA of the hip (Tönnis grade 2 and 3) for at least two years after surgery. We thus consider the procedure to be a reasonable option for patients with hip OA, although success of the procedure will be less than if undertaken for certain other conditions.

Clinical outcome scores for arthroscopic femoral osteochondroplasty in femoroacetabular impingement: a quantitative systematic review

BACKGROUND AND AIMS

Femoroacetabular impingement is the abnormal contact of the proximal femur and acetabulum during motion. It causes hip pain and joint degeneration in young patients. This systematic review aims to clarify the clinical effect of arthroscopic femoral osteochondroplasty for cam lesions and to review the available literature for the general medical readership, including providers of primary and secondary care.

METHODS AND RESULTS

Electronic databases were searched for studies of arthroscopic femoral osteochondroplasty in primary femoroacetabular impingement. A total of 2618 article titles, 242 abstracts and 33 full text articles were considered. Ultimately nine studies with clinical outcome scores met the inclusion criteria and were included in the qualitative systematic review. Six studies were suitable for meta-analysis using an inverse variance, random effects model (RevMan software). In the nine studies, improvements were seen in Western Ontario and McMaster Universities Osteoarthritis index, Non-arthritic Hip Score and Modified Harris Hip Scores. Across the six studies suitable for meta-analysis (537 patients), a 24-point weighted mean improvement in Non-arthritic hip score was seen. This yielded a large overall effect size of 1.6.

CONCLUSION

Arthroscopic femoral osteochondroplasty appears to be a beneficial treatment for primary femoroacetabular impingement, with a large effect size seen across six eligible studies.

Outcome of arthroscopic treatment for symptomatic femoroacetabular impingement

Background

Recently, arthroscopic-based treatment for hip-related pain with radiological findings of femoroacetabular impingement and labral lesions has been developed.

We aim to present clinical outcome in a single centre patient cohort of patients treated arthroscopically for hip-related pain due to femoroacetabular impingement.

Methods

A total of 117 consecutive patients operated in 2009–2011 were included in this prospective case series (41% male; mean age 37 years; (range 15–70). The indication for arthroscopic treatment of hip-related pain was mechanical hip symptoms and radiological findings of femoroacetabular impingement.

To evaluate hip function and pain level at 1-year and 2–5 years follow up (FU) mHHS (Modified Harris Hip Score), HOS (Hip Outcome Score) and a Numeric Rating Scale (NRS) pain score were used.

Results

Labral tears were seen in 91% of the hip arthroscopies. Cartilage lesions (ICRS grade 2 and above) were seen at the acetabular and femoral articular surfaces in 79% and 15% of cases, respectively. The therapeutic procedures were in 99% of the arthroscopies osteochondroplasty and/or acetabular rim-trimming. In 77% of procedures labral reattachment was performed. The patient evaluated outcome demonstrated significant increases in mHHS and HOS at 1-year follow up and at final FU compared to preoperatively (1 yr: mHHS: 72.1 to 85.3, HOS: 71.4 to 85.1; final FU: mHHS: 72.1 to 83.8, HOS: 71.4 to 83.7). Pain levels decreased significantly from preoperatively to follow ups. Five patients underwent total hip replacement within the follow up period after hip arthroscopy.

Conclusions

Arthroscopic treatment of femoroacetabular impingement improves patient evaluated outcomes. Further studies are needed to determine failure rates and risk factors.

A comprehensive five-phase rehabilitation programme after hip arthroscopy for femoroacetabular impingement

PURPOSE

Recent advancements in the understanding of hip biomechanics have led to the development of techniques to remove bony impingement and repair and/or preserve the labrum during hip arthroscopy. Although much attention in the literature is devoted to diagnosis and treatment, there is little information about post-operative rehabilitation. Therefore, the purpose of this review is to (1) provide a five-phase rehabilitation protocol following arthroscopic treatment for FAI and (2) report clinical and functional outcomes of patients following this protocol at minimum 1-year follow-up, in order to provide the surgeon and therapist with a protocol that is supported by clinical data.

METHODS

All consecutive patients undergoing hip arthroscopy and subsequent five-phase rehabilitation protocol at a single institution from 1 April 2011 to 1 April 2012 were analysed. Inclusion criteria were as follows: no prior ipsilateral hip surgery, completion of the five-phase rehabilitation protocol, minimum 1-year follow-up, and documented outcome scores. Prospective outcomes were assessed with modified Harris hip score (MHHS) and hip outcome score (HOS).

RESULTS

Fifty-two patients (19 male and 33 female) met the inclusion criteria with a median age of 42 (range 16-59) years. Mean MHHS, HOS-ADL, and HOS-sport scores at a mean 12.5 (range 12-15) months were 80.1 ± 19.9 (0-100), 83.6 ± 19.2 (13.2-100), and 70.3 ± 27.0 (0-100), respectively.

CONCLUSION

This five-phase rehabilitation programme provides a framework where progression from surgery to increasing post-operative activity level can take place in a predictable manner. Patients following this rehabilitation protocol after hip arthroscopy demonstrated satisfactory clinical and functional outcomes, validating its implementation.