Survivorship and Outcomes 10 Years Following Hip Arthroscopy for Femoroacetabular Impingement: Labral Debridement Compared with Labral Repair

Pain worsens peripartum after hip arthroscopy for femoroacetabular impingement and may not return to pre-pregnancy improvement

Purpose

To assess hip symptomatology during the perioperative and peripregnancy periods and postoperative outcomes among reproductive age females undergoing arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) and pregnancy complications in females after hip arthroscopy.

Methods

Females aged 18-44 years who underwent hip arthroscopy for the treatment of FAIS with a single surgeon were included in the study. Postoperatively, patients were surveyed regarding obstetric history, hip symptomology, and post-surgery pregnancy experiences. Subjects were classified as nulligravid (Group 1), pregnant at least once before hip surgery but never again following surgery (Group 2), or pregnant at least once following hip surgery (Group 3). Hip pain intensity was reported on a 10-point Visual Analog Scale (VAS) and hip function was reported using the modified Harris Hip Score (mHHS). Patients self-reported pregnancy outcomes and complications.

Results

85 patients were enrolled with a mean age of 32.3 ± 6.5 years at the time of surgery. Mean follow-up time was 51.9 ± 34.5 months. There were 39 subjects in Group 1 (45.9 %), 20 in Group 2 (23.5 %), and 26 in Group 3 (30.6 %). There were no significant inter-group differences in mHHS preoperatively or at final follow-up (p = 0.95). Group 3 subjects reported that both postoperative and post-pregnancy VAS remained significantly lower than the preoperative baseline (p < 0.001). 69.2 % and 73.1 % report worsened hip pain during the third trimester and postpartum, respectively. 57.9 % reported that their hip pain returned to the pre-pregnancy baseline by time of survey completion.

Conclusion

Females of reproductive age with FAIS can expect clinical improvements relative to their baseline after hip arthroscopy regardless of pregnancy timing relative to surgical intervention. A majority of patients who become pregnant post-arthroscopy experience a peripartum recurrence of their symptoms. Most but not all of these patients return to the level of maximal improvement they had initially experienced postoperatively.

Good Mid-Term Clinical Outcomes and Low Arthroplasty Conversion Rates After Hip Arthroscopy with Labral Debridement Without Refixation or Reconstruction

Introduction: The present study investigates the five-year outcomes of hip arthroscopy for cam or pincer-type femoroacetabular impingement (FAI) and associated labral tears in a defined patient population. Methods: Patients who underwent hip arthroscopy for cam or pincer-type arthroscopy femoroacetabular impingement (FAI) and labral tears at our hospital in the past five years were included. All patients who underwent revision-like a total hip arthroplasty (THA), a subsequent hip arthroscopy at another hospital, or had primary osseous diseases-were excluded. Patients were contacted via mail and asked to answer a clinical questionnaire called the "Hip Osteoarthritis Outcome Score" (HOOS) and to indicate whether there was a second surgery like a subsequent arthroscopy or THA. Results: There were 77 hip arthroscopies in 75 patients the last 5 years. A total of 29 patients responded. Those who did not respond were contacted via phone. All in all, we obtained the results of 49 patients (50 hips-29 right, 19 left, and 1 bilateral) who underwent hip arthroscopy over the past five years. The mean age at the time of operation was 41 years. Our results were as follows: 24 hips had an isolated labral tear, 49 hips a combined FAI pathology with cam and/or pincer-type impingement and labral tears, 3 patients had a posttraumatic FAI, and 1 patient suffered from hip chondromatosis, who was subsequently excluded; further, 22 patients (23 procedures) were lost to follow-up. HOOS contains various subscales; only the postoperative result of subscale 1 (symptoms) did not show a statistically significant improvement compared with the preoperative value. All other subscales showed a statistically significant improvement in comparison with the preoperative condition. Five patients (10.2%) still experienced symptoms, so we performed a total hip arthroplasty (THA) as a second surgical procedure. One patient was revised due to chondromatosis. One patient was revised at another center, and another was excluded because of chondromatosis. Conclusions: The five-year follow-up results of hip arthroscopy proved successful outcomes. Hip arthroscopy is an effective treatment for FAI in order to delay primary THA, regaining mobility and range of motion and reducing pain. Longer-term studies with a larger cohort are necessary.

Long-term outcomes of arthroscopic management of femoroacetabular impingement syndrome: a systematic review

INTRODUCTION

Femoroacetabular impingement (FAI) syndrome is a condition characterised by irregularities in the femur or acetabular rim, leading to hip pain, increased risk of osteoarthritis (OA), and potential need for total hip arthroplasty (THA). Non-surgical treatments are the first-line approach. However, arthroscopic surgery has become more prevalent due to its promising short- and medium-term outcomes. Recent meta-analyses suggest that hip arthroscopy may offer superior results compared to non-operative treatments, though follow-up periods in these studies have been limited to 12 months. This systematic review aims to evaluate the long-term effectiveness of arthroscopic management for FAI syndrome, hypothesising that it will significantly improve patient-reported outcomes (PROMs) over a follow-up period exceeding ten years.

METHODS

The review focused on studies published in peer-reviewed journals with a minimum follow-up of 120 months and assessed outcomes such as PROMs and complication rates. It adhered to PRISMA guidelines and used the PICOT algorithm to evaluate the literature. Data extraction covered study characteristics, PROMs, and complications. Statistical analyses were conducted using IBM SPSS software to summarise continuous and dichotomous data.

RESULTS

Of 1,245 identified articles, 7 were included after rigorous screening. Risk of bias assessment with the ROBINS-I tool revealed a serious or moderate risk of bias due to confounding, although overall methodological quality was acceptable. Data from 478 patients showed significant improvements in PROMs from baseline to follow-up.

CONCLUSION

This systematic review indicates that arthroscopic management for FAI syndrome significantly improves PROMs with a mean follow-up of approximately 130 months. Nevertheless, 32% of patients required THA within ten years, underscoring the importance of careful patient selection and consideration of factors like OA and age. While conservative treatments such as physical therapy may yield comparable short-term outcomes, recent evidence suggests that arthroscopy provides superior results, particularly for younger patients and those without preoperative OA.

LEVEL OF EVIDENCE

Level II, systematic review and meta-analysis.

Sport Participation Is Associated with Superior 10-Year Patient Acceptable Symptom State Achievement Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Sport participation has been associated with favorable outcomes following hip arthroscopy (HA) for femoroacetabular impingement (FAI) at short- and mid-term follow-up; however, few studies have evaluated the 10-year outcomes in this population. The purpose of this study was to compare patient-reported outcome measures (PROMs), the achievement of clinically significant outcomes, and reoperation-free survivorship between patients with and without regular preoperative sport participation who underwent HA for FAI and had a minimum of 10 years of follow-up.

METHODS

Data were prospectively collected for patients who underwent primary HA for FAI between January 2012 and September 2013. Patients who participated in weekly sport participation at the time of surgery ("athletes") were matched 1:1 to patients who denied sport participation ("nonathletes"), controlling for age, sex, and body mass index (BMI). Preoperative and 10-year postoperative PROMs were collected, including the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports (HOS-Sports) subscales, the modified Harris hip score (mHHS), and the visual analog scale for pain (VAS Pain) and satisfaction (VAS Satisfaction). Patient acceptable symptom state (PASS) achievement and reoperation-free survivorship were compared between the groups.

RESULTS

Sixty-four athletes were matched to 64 nonathletes of similar age, sex, and BMI (p ≥ 0.411). In the athlete group, 85.9% were recreational-level athletes. The groups had similar preoperative PROMs, except for the HOS-ADL subscale, where the athlete group demonstrated a higher preoperative score (67.8 ± 16.7 versus 59.9 ± 21.1, p = 0.029). Both groups demonstrated a significant improvement in all PROMs (p < 0.001) at the minimum 10-year follow-up10.3 ± 0.4 years). At the time of the final follow-up, the athlete group demonstrated significantly higher scores across all of the measured PROMs (p ≤ 0.036). Athletes showed a higher cumulative PASS achievement compared with nonathletes for the HOS-ADL subscale (73% versus 50%, p = 0.033), the HOS-Sports subscale (85% versus 61%, p = 0.010), the mHHS (69% versus 43%, p = 0.013), and the VAS Pain (78% versus 51%, p = 0.006). Reoperation-free survivorship frequencies were 87.5% and 82.8%, respectively (p = 0.504).

CONCLUSIONS

Athletes who underwent contemporary HA for FAI showed superior PROMs and PASS achievement compared with nonathletes at the 10-year follow-up. Athletes and nonathletes showed reoperation-free survivorship frequencies of 87.5% and 82.8%, respectively.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Primary and Revision Hip Arthroscopy in Borderline Hip Dysplasia Shows Comparable Outcomes at a Minimum 5-Year Follow-Up

PURPOSE

To compare patient-reported outcomes (PROs), achievement of clinically significant outcomes, and reoperation-free survivorship between primary and revision hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in propensity-matched borderline hip dysplasia (BHD) patients at a minimum 5-year follow-up.

METHODS

Patients with BHD, characterized by a lateral center-edge angle 18° to 25°, who underwent HA for FAIS with capsular repair by a single surgeon between January 2012 and June 2018 with a minimum 5-year follow-up were identified. Cases of revision HA were propensity-matched 1:2 to cases of primary HA, controlling for age, sex, and body mass index. A 1:2 ratio was chosen to maximize the number of included patients. Collected PROs included Hip Outcome Score-Activities of Daily Living and Sport Subscales, International Hip Outcome Score 12, modified Harris Hip Score, and Visual Analog Scale for Pain. Achievement of minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit for any measured PRO was compared between groups along with reoperation-free survivorship using Kaplan-Meier analysis.

RESULTS

Thirty-six revision HA hips (34 patients) were propensity-matched to 72 primary HA hips (70 patients). The groups were similar in age (31.5 ± 10.3 years vs 30.5 ± 11.2, P = .669), sex (69.4% female vs 70.8%, P = .656), and body mass index (25.7 ± 4.0 vs 25.5 ± 3.7, P = .849). The revision group showed a greater prevalence of prolonged preoperative pain (50.0% vs 27.8%, P = .032) compared with the primary group. A significant improvement in all PROs was observed for both groups with comparable PROs preoperatively and at the 5-year follow-up between groups (P ≥ .086). The revision and primary groups showed comparable minimal clinically important difference (95.0% vs 95.7%, P ≥ .999), patient acceptable symptom state (80.0% vs 83.6%, P = .757), and substantial clinical benefit (62.5% vs 70.7%, P = .603) achievement for any PRO. Comparable reoperation-free survivorship was observed (P = .151).

CONCLUSIONS

Propensity-matched patients with BHD undergoing primary and revision hip arthroscopy for FAIS achieved similar minimum 5-year PROs, clinically significant outcomes, and reoperation-free survivorship.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Increased Risk of Femoral Neck Stress Fractures in Patients With Cam or Pincer Morphology

Previous studies suggest a relationship between femoroacetabular impingement (FAI) and femoral neck stress fractures (FNSF), due to pathologic biomechanics in the setting of femoral head abutment (cam morphology) and/or acetabular overcoverage (pincer morphology). The purpose of this study is to evaluate the association between cam or pincer morphology and FNSF, compared to a control group of patients without hip pain. A retrospective review of the electronic medical record at a single institution was queried for patients with FNSF over a 10-year time period from January 2011-2021. These patients were compared to a control group with diagnostic radiographs and a chief complaint that was not hip pain presenting to the institution's emergency department. Hip morphology was evaluated radiographically. A multivariate logistic regression was used to investigate an association between FNSF and cam or pincer morphology. Eighty-three patients with FNSF and a mean age of 38.6 years were compared to 55 healthy controls with a mean age of 35.8 years. Patients in the FNSF group were more often female, white, and had lower BMI. These patients were also more likely to have associated cam morphology (p = 0.010). Binary logistic regression demonstrated a statistically significant independent association between both cam (OR 5.2, p = 0.01) and pincer (OR 4.6, p = 0.022) morphology with FNSF when controlling for demographic variables. Black race and higher BMI were protective factors for FNSF (OR 0.09, OR 0.84, p < 0.01). In summary, radiographic cam morphology, superolateral acetabular overcoverage, female sex, and lower BMI are risk factors for sustaining FNSF, while the black race was found to be protective.

Mechanical properties and biocompatibility characterization of 3D printed collagen type II/silk fibroin/hyaluronic acid scaffold

Damage to articular cartilage is irreversible and its ability to heal is minimal. The development of articular cartilage in tissue engineering requires suitable biomaterials as scaffolds that provide a 3D natural microenvironment for the development and growth of articular cartilage. This study aims to investigate the applicability of a 3D printed CSH (collagen type II/silk fibroin/hyaluronic acid) scaffold for constructing cartilage tissue engineering. The results showed that the composite scaffold had a three-dimensional porous network structure with uniform pore sizes and good connectivity. The hydrophilicity of the composite scaffold was 1071.7 ± 131.6%, the porosity was 85.12 ± 1.6%, and the compressive elastic modulus was 36.54 ± 2.28 kPa. The creep and stress relaxation constitutive models were also established, which could well describe the visco-elastic mechanical behavior of the scaffold. The biocompatibility experiments showed that the CSH scaffold was very suitable for the adhesion and proliferation of chondrocytes. Under dynamic compressive loading conditions, it was able to promote cell adhesion and proliferation on the scaffold surface. The 3D printed CSH scaffold is expected to be ideal for promoting articular cartilage regeneration.

High satisfaction and low conversion rate to total hip arthroplasty after hip arthroscopy for femoroacetabular impingement syndrome and risk factors affecting survival at long-term follow-up

PURPOSE

Studies evaluating the long-term survival rate, patient satisfaction, and conversion to total hip arthroplasty (THA) are limited. The aim of this study was to evaluate satisfaction and hip survival at a minimum 10-year follow-up in patients following hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

A total of 164 patients underwent hip arthroscopy for FAIS between 2007 and 2012; of these, 76 (49 men and 27 women; mean age, 40.7 ± 11.2 years; range, 15-69 years) patients could be clinically examined or reached by phone or email and included in the study. Prospectively collected data of these patients who followed for a minimum of 10 years were retrospectively analysed. Patients who had previous trauma or surgery on the hip or were younger than 15 years were excluded. Of the 76 patients, 37 (48.7%) had mixed type, where 29 (38.2%) had cam and 10 (13.2%) had pincer type FAIS. Patient demographics, Tonnis grade for osteoarthritis and intraoperative findings were reviewed. Outcome measures of interest included reoperations (re-arthroscopy, conversion to THA), patient satisfaction, ability to return to sports, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), modified Harris Hip Score (mHHS) and some possible factors associated with conversion to THA.

RESULTS

The mean follow-up was 12.4 ± 1.8 (10-16 years). Twenty-one per cent required conversion to THA, with a mean time requiring THA of 4.8 ± 1.7 years (2-8 years). Mean age of the patients requiring THA was 47.8 ± 8.2 years. Two (2.6%) patients required re-arthroscopy. Fifty-eight (76.3%) patients did not undergo any revision surgery or other treatments. Forty-seven (61.8%) patients were completely satisfied with the results, where 5 (6.6%) patients were very satisfied and 4 (5.3%) patients were satisfied. Overall satisfaction rate was 73.7%. Mean postoperative mHHS score was 76.5 ± 15.5 and the mean WOMAC score was 84.0 ± 16.0. Return-to-sports rate was 85%, and the return to the old sport level was 67.1%. Age over 40 years (p = 0.004), a Tonnis Grade >1 (p < 0.001) and a full-thickness acetabular chondral lesion (p = 0.001) were identified as factors for failure and conversion to THA.

CONCLUSIONS

Hip arthroscopy for FAIS resulted in high satisfaction of patients who did not eventually require THA. Higher rates of conversion to THA were seen in older patients, patients treated with higher Tonnis grade and full-thickness acetabular chondral lesions.

LEVEL OF EVIDENCE

Level IV, case series.

Six-Month Outcomes Correlate With 10-Year Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To identify whether 6-month outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) correlate with outcomes at minimum 10-year follow-up.

METHODS

Patients who underwent primary hip arthroscopy for FAIS from 2012 to 2013 were reviewed and included if they had 6-month and minimum 10-year follow-up. Patient-reported outcome (PRO) measures included the Hip Outcome Score Activities of Daily Living (HOS-ADL) subscale, Hip Outcome Score Sports-Specific (HOS-SS) subscale, modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain, and VAS for satisfaction. We compared 6-month and 10-year outcome scores and analyzed the relations between 6-month and 1-, 2-, 5-, and 10-year outcome scores using Pearson correlation coefficients (r). Six-month scores and clinically significant outcome achievement were then compared with 10-year clinically significant outcome achievement and reoperations, including revision hip arthroscopy and conversion to total hip arthroplasty (THA), using logistic regressions and the Fisher exact test.

RESULTS

This study included 60 patients (60.0% female sex; mean age, 36.0 ± 12.2 years). The mHHS, VAS pain score, and VAS satisfaction score significantly improved from 6-month to 10-year follow-up (P ≤ .021), whereas the HOS-ADL and HOS-SS did not (P ≥ .072). There were significant correlations between 6-month and 10-year scores for the HOS-ADL (r = 0.505), HOS-SS (r = 0.592), and mHHS (r = 0.362) (P ≤ .022 for all), as well as significant correlations between 6-month and 1-, 2-, and 5-year scores (P ≤ .014 for all). The 6-month HOS-ADL, HOS-SS, and mHHS were all significantly associated with their respective 10-year achievement of the patient acceptable symptom state (PASS) (P ≤ .044). Furthermore, 6-month HOS-ADL and mHHS were significantly associated with THA conversion (P ≤ .041). Comparable 6-month and 10-year achievement of the minimal clinically important difference (96.5% vs 97.8%, P > .999) and PASS (85.2% vs 87.5%, P > .999) for any PRO was observed.

CONCLUSIONS

After hip arthroscopy for FAIS, patients' 6-month HOS-ADL and mHHS were significantly associated with their 10-year PROs, PASS achievement, and THA conversion, although correlation strengths decreased with increasing time from surgery.

LEVEL OF EVIDENCE

Level IV, case series.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Comparison of Interportal and Periportal Capsulotomies and Axial Distraction Resistance During Hip Arthroscopy: An In Vivo Propensity-Matched Cohort Study

BACKGROUND

Intraoperative hip capsule management is increasingly recognized as an important component of hip arthroscopy for the prevention of capsular-related instability. The periportal capsulotomy, relative to the interportal capsulotomy, has been proposed as a minimally invasive technique for decreasing postarthroscopy hip instability; however, the biomechanical effects of this technique are not well established.

PURPOSE/HYPOTHESIS

This study aimed to provide a biomechanical characterization of interportal and periportal capsulotomies, helping inform surgeon choice of capsulotomy type and repair, potentially guiding clinical practice in hip arthroscopy. The authors hypothesized that the periportal capsulotomy would demonstrate greater resistance to axial distraction in all capsular states.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients undergoing primary hip arthroscopy by a single surgeon underwent intraoperative axial distraction testing at 25-, 50-, 75-, and 100-pound force intervals, with each axial distraction distance measured by standardized fluoroscopic evaluation. Propensity matching was conducted between the periportal group and the interportal group using native state distraction, lateral center-edge angle, and sex as covariates to achieve balance between groups. Between-group comparisons of distraction distances were then conducted using the Student t test and Fisher exact test.

RESULTS

In total, 74 interportal capsulotomies and 124 periportal capsulotomies were identified. Propensity matching yielded 74 hips in each group. Demographic and radiographic characteristics were similar between matched cohorts (P > .05). An unrepaired interportal capsulotomy led to an increase in hip distraction of 2.74 mm at 100 lbf (P < .001) compared with the native state, whereas unrepaired periportal capsulotomy led to an increase of 2.43 mm at 100 lbf (P < .001). Distraction distances were similar between the interportal and periportal groups in both the capsulotomy and repair states (P > .05), while the periportal capsulotomy repair demonstrated decreased hip distraction distance when compared with the native state by 1.37 mm at 75 lbf and 1.45 mm at 100 lbf (P < .001).

CONCLUSION

In a propensity-matched cohort analysis, an unrepaired periportal capsulotomy and interportal capsulotomy have similar effects on increasing hip axial distraction distance intraoperatively. Performing a capsular repair restores intraoperative resistance to axial distraction in both procedures. Despite the minimal disruption of the capsule with periportal techniques, repair is required for restoration of native biomechanics.

Knotless Versus Knotted Suture Anchors for Labral Repair of the Hip: A Systematic Review of Clinical and Biomechanical Outcomes

BACKGROUND

Arthroscopic labral repair of the hip is successfully performed with increasing frequency using either knotless or knotted suture anchors, each with its own risks and benefits.

PURPOSE

To examine biomechanical and clinical outcomes for labral repair of the hip based on the use of knotted or knotless suture anchors.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A search was performed to retrieve clinical and biomechanical studies examining the use of knotless or knotted suture anchors for arthroscopic labral repair of the hip. The studied outcomes included functional outcome scores such as modified Harris Hip Score (mHHS) and Hip Outcome Score Activities of Daily Living, biomechanical outcomes, failure mechanisms, and complications such as revision/reoperation and conversion to total hip arthroplasty (THA).

RESULTS

A total of 47 articles met inclusion criteria for analysis (5 articles examining biomechanical outcomes and 42 reporting clinical outcomes). Included patients (N = 6185) who underwent hip labral repair had a mean age of 33.0 ± 8.5 years and follow-up time of 43.8 ± 18.4 months. The knotless group (n = 2719) had a mean preoperative mHHS of 63.3 ± 4.1 and postoperative mHHS of 86.3 ± 2.8 at a mean follow-up time of 47.2 ± 16.1 months. The knotted group (n = 2600) had a mean preoperative mHHS of 69.5 ± 8.3 and postoperative mHHS of 88.8 ± 5.5 with a mean follow-up time of 44.8 ± 18.1 months. The most common reason for failure of knotless anchors in biomechanical studies was suture breakage or pullout, and for knotted anchors it was anchor pullout. Of the articles reporting on revisions and/or conversion to THA after labral repair, the knotless group had 225 reoperations (8.1%) and 123 cases of conversion to THA (4.4%). The knotted group had 101 reoperations (6.2%) and 31 cases of conversion to THA (1.9%).

CONCLUSION

Arthroscopic management of labral repairs of the hip using either knotless or knotted suture anchors appears to be both safe and effective in reducing pain and improving function. Biomechanical evaluation suggests differing failure mechanisms in knotted versus knotless anchors. The rates of revision and conversion to THA are low overall, irrespective of knotted or knotless anchors.

Femoroacetabular Impingement: Preoperative Planning and Postoperative MR Imaging Evaluation

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

Moderate burden amongst caregivers posthip arthroscopy linked to younger caregiver age and task load: A cross-sectional survey study

PURPOSE

To evaluate the burden experienced by primary informal caregivers of patients who have undergone hip arthroscopy and to identify factors that predict increased caregiver burden.

METHODS

A cross-sectional study was conducted at a single academic hospital centre, enroling caregivers of patients who underwent hip arthroscopy between November 2018 and November 2023. Caregiver burden was assessed using the Caregiver Burden Inventory (CBI) survey. Multivariable linear regression models were used to identify predictors of caregiver burden, with the global CBI score serving as the primary outcome measure. Secondarily, open-ended survey questions were analyzed qualitatively to elucidate specific challenges and facilitators of caregiving, as reported by the caregivers themselves.

RESULTS

The study involved 99 eligible caregivers (mean [standard deviation] age; 47 [11] years), 58% were female, and 85% were relatives of the patient. The median global CBI score was 13.0 (interquartile range: 8.0-22.4), indicating a moderate burden. Regression analyses demonstrated that younger caregiver age and a higher number of caregiving tasks were significant predictors of increased global burden. Additionally, nonweightbearing status of patients, female gender of caregivers and working full-time statistically significantly increased specific dimensions of caregiver burden.

CONCLUSION

This study highlights the meaningful burden faced by caregivers of patients undergoing hip arthroscopy, despite its minimally invasive nature and outpatient setting. Identified risk factors such as younger caregiver age, female gender of the caregiver, nonweight-bearing status and increased caregiving tasks suggest targeted areas for intervention. The qualitative analysis revealed that caregivers struggle with time management and physical and emotional strain, yet better communication and practical support from healthcare teams could help to alleviate these challenges.

LEVEL OF EVIDENCE

Level IV, prognostic study.

Efficacy of iliopsoas plane block for patients undergoing hip arthroscopy: a prospective, triple-blind, randomized, placebo-controlled trial

BACKGROUND

Intraoperative stretching of the hip joint capsule often generates severe pain during the first 3 hours after hip arthroscopy. The short-lived severe pain mandates high opioid consumption, which may result in adverse events and delay recovery. The femoral nerve nociceptors are located anteriorly in the hip joint capsule. A femoral nerve block reduces pain and opioid demand after hip arthroscopy. It impedes, however, ambulation and home discharge after outpatient surgery. The iliopsoas plane block selectively anesthetizes the femoral sensory nerve branches innervating the hip joint capsule without compromising ambulation. We aimed to assess reduction of opioid consumption after iliopsoas plane block during the short-lived painful postsurgical period of time after hip arthroscopy.

METHODS

In a randomized, triple-blind trial, 50 patients scheduled for hip arthroscopy in general anesthesia were allocated to active or placebo iliopsoas plane block. The primary outcome was opioid consumption during the first three postoperative hours in the postanesthesia care unit. Secondary outcomes included pain, nausea, and ability to ambulate.

RESULTS

Forty-nine patients were analyzed for the primary outcome. The mean 3-hour intravenous morphine equivalent consumption in the iliopsoas plane block group was 10.4 mg vs 23.8 mg in the placebo group (p<0.001). No intergroup differences were observed for the secondary outcomes during the postoperative follow-up.

CONCLUSION

An iliopsoas plane block reduces opioid consumption after hip arthroscopy. The reduction of opioid consumption during the clinically relevant 3-hour postsurgical period of time was larger than 50% for active versus placebo iliopsoas plane block in this randomized, triple-blind trial.

Medium-term results of arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of femoroacetabular impingement syndrome: a multi-centre randomised controlled trial

OBJECTIVE

To report a 3-year follow-up from the FemoroAcetabular Impingement Trial, comparing arthroscopic surgery with physiotherapy in the management of femoroacetabular impingement (FAI) syndrome for the dual primary outcomes of radiographic hip osteoarthritis (OA) and patient-reported outcome measures of activities of daily living.

METHODS

Two-group parallel, assessor-blinded, pragmatic randomised controlled trial across seven sites. 222 participants aged 18-60 years with FAI syndrome confirmed clinically and radiologically were randomised (1:1) to receive arthroscopic hip surgery (n=112) or physiotherapy (n=110). Dual primary outcome measure was minimum joint space width (mJSW) on anteroposterior radiograph at 38 months post-randomisation and Hip Outcome Score ADL (HOS ADL) (higher score indicates superior outcomes). Secondary outcome measures were Scoring Hip Osteoarthritis with MRI (SHOMRI) (lower score indicates less pathology).

RESULTS

mJSW, HOS ADL and MRI data were available for 45%, 77% and 62% of participants at 38 months, respectively. No significant difference in mJSW was seen between groups at 38 months. HOS ADL was higher in the arthroscopy group (mean (SD) 84.2 (17.4)) compared with the physiotherapy group (74.2 (21.9)), difference 8.9 (95% CI 7.0, 10.8)). SHOMRI score total at 38 months was lower in the arthroscopy group (mean (SD) 9.22 (11.43)) compared with the physiotherapy group (22.76 (15.26)), differences (95% CIs) -15.94 (-18.69, -13.19).

CONCLUSIONS

No difference was seen between groups on radiographic measures of OA progression. Patients with FAI syndrome treated surgically may experience superior pain and function outcomes, and less MRI-measured cartilage damage compared with physiotherapy.

TRIAL REGISTRATION NUMBER

NCT01893034.

Accelerated rehabilitation and return to sport after hip arthroscopy for femoroacetabular impingement syndrome is safe and effective

Present recommendations in the literature advocate for a return to sport (RTS) between 5- and 10 months following hip arthroscopy for femoroacetabular impingement (FAI). We have adopted the International Society of Hip Preservation protocol with modifications for the rehabilitation of our patients. The aim of the present study was to examine the time to RTS with this rehabilitation approach after hip arthroscopy for FAI. It was hypothesized that most athletes will RTS by 5 months post-surgery without any adverse effects. Patients undergoing hip arthroscopy for FAI were prospectively followed with preoperative and postoperative Patient Reported Outcome Measures including: Modified Harris Hip Score (mHHS) and Copenhagen Hip and Groin Outcome Score (HAGOS). Preinjury sports and competition level, postoperative RTS rate, time, and level, complications, and revision surgeries were recorded. A total of 56 patients were identified for inclusion (36.6 ± 14.1 years old at date of surgery, 34 females and 22 males). There were 35 recreational athletes and 21 competitive-level athletes (10 in high-demand sports and 11 in moderate-demand sports). In all, 44 patients (79%) returned to sport at 5.3 ± 3.5 months postoperatively. Of the 12 patients who did not RTS, 5 (42%) did not return for reasons other than their hip. Neither HAGOS (P = .458) nor mHHS (P = .424) differed between athletes with RTS in ≤ 5 months (HAGOS: 80.4 ± 22.3; mHSS: 88.0 ± 17.7) versus >5 months (HAGOS: 84.6 ± 11.8; mHSS: 91.5 ± 8.7). The current study demonstrates that accelerated rehabilitation after hip arthroscopy for FAI can safely return athletes to sport within 6 months.

Demographic Disparities and Outcomes Following Hip Arthroscopy: Exploring the Impact of Social Determinants of Health in Femoroacetabular Impingement Syndrome

BACKGROUND

The purpose of this study was to explore the impact of social deprivation on preoperative characteristics and postoperative outcomes following hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients undergoing primary HA for FAIS were identified, and their social deprivation index (SDI) score was assigned on the basis of the provided ZIP code. Quartiles (Q1 to Q4) were established using national percentiles, with Q4 representing patients from the areas of greatest deprivation. Patient-reported outcomes (PROs) were collected preoperatively and at a minimum follow-up of 2 years. Achievement rates for clinically meaningful outcomes, including the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and substantial clinical benefit (SCB), were determined. The incidences of revision HA and conversion to total hip arthroplasty (THA) were recorded. SDI groups were compared with respect to preoperative characteristics and postoperative outcome measures. Predictors of MCID, PASS, and SCB achievement; revision HA; and conversion to THA were identified with use of multivariable logistic regression.

RESULTS

In total, 2,060 hips were included, which had the following SDI distribution: Q1 = 955, Q2 = 580, Q3 = 281, and Q4 = 244. The composition of the included patients with respect to race and/or ethnicity was 85.3% Caucasian, 3.8% African American, 3.7% Hispanic, 1.7% Asian, and 5.4% "other." Patients with more social deprivation presented at a later age and with a higher body mass index (BMI), a longer duration of preoperative hip pain, and greater joint degeneration (p ≤ 0.035 for all). The most socially deprived groups had higher proportions of African American and Hispanic individuals, less participation in physical activity, and greater prevalences of smoking, lower back pain, and Workers' Compensation (p ≤ 0.018 for all). PRO scores and achievement of the PASS and SCB were worse among patients from areas of greater social deprivation (p ≤ 0.017 for all). Age, BMI, activity status, race and/or ethnicity classified as "other," SDI quartile, Workers' Compensation, preoperative back pain, duration of preoperative hip pain, and Tönnis grade were independent predictors of clinically meaningful outcome achievement, revision arthroscopy, and/or THA conversion (p ≤ 0.049 for all).

CONCLUSIONS

Individuals with more social deprivation demonstrated inferior postoperative outcome measures. This was driven primarily by preoperative characteristics such as SDI, hip pain duration, joint degeneration, and overall health at presentation. Despite differential outcomes, patients still showed clinical improvement regardless of SDI quartile.

LEVEL OF EVIDENCE

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

Circumferential Labral Reconstruction With Knotless All-Suture Anchors Restores Hip Distractive Stability: A Cadaveric Biomechanical Analysis

BACKGROUND

The essential component of managing femoroacetabular impingement involves restoration of the original labral function. Circumferential labral reconstruction (CLR) has shown positive results. However, biomechanical studies of CLR are limited and have not established the efficacy of the modern knotless all-suture anchor (ASA) pull-through technique.

HYPOTHESES

(1) CLR with knotless ASA fixation will restore native labral suction seal biomechanics; (2) tensioning the ASA to a high-tension state will increase the peak distractive force.

STUDY DESIGN

Controlled laboratory study.

METHODS

Eight fresh-frozen human cadaveric hips were dissected free of all soft tissue except the native labrum and transverse acetabular ligament. On an electromechanical testing system, the hips were compressively loaded to 250 N to initiate a suction seal and distracted at a rate of 10 mm/s until rupture of the suction seal. Hips were tested in 4 states: intact labrum, full labral removal, knotless CLR with moderate anchor tension, and CLR with high anchor tension. Peak distractive force (in newtons) was compared using repeated measures analysis of variance (P < .05). Acetabular bevel angles (θ) were measured at labral clockface positions outside the transverse acetabular ligament using a 3-dimensional digitizer stylus after rim preparation. Linear regression plots compared θ and peak distractive force in the CLR state.

RESULTS

Peak force values were 138.5 ± 13.6 N (mean ± SE) for the intact labrum, 18.4 ± 2.79 N for labral excision, 95.4 ± 23.3 N for moderate-tension CLR, and 126.2 ± 27.3 N for high-tension CLR. Significant differences were observed only when full labral removal was compared with the other conditions: intact (P < .001), moderate-tension CLR (P = .016), and high-tension CLR (P = .002). Steeper acetabular bevel angles (smaller θ) were correlated with greater suction seal restoration (P < .05).

CONCLUSION

CLR restored distractive stability on average to 82.0% of the intact value after labral deficiency. Retensioning did not significantly increase peak distractive forces.

CLINICAL RELEVANCE

These findings provide biomechanical validation supporting CLR using knotless ASAs in an effort to minimize volumetric bone loss and provide other surgical advantages. The prepared rim's bevel angle may be an important variable to optimize for improved suction seal restoration.

Defining Clinically Significant Outcome Thresholds for the Patient-Reported Outcomes Measurement Information System (PROMIS) at 2 Years After Gluteus Medius and/or Minimus Repair

Background

Clinically significant outcome (CSO) thresholds are invaluable to the interpretation of patient-reported outcomes (PROs). The Patient-Reported Outcomes Measurement Information System (PROMIS) is gaining popularity among the orthopaedic community; however, CSO thresholds for PROMIS are yet to be defined for outcomes after gluteus medius and/or minimus (GM) repair.

Purpose

To (1) define CSO thresholds for PROMIS-Pain Interference (PROMIS-PI) and PROMIS-Physical Function (PROMIS-PF) after GM repair, (2) correlate these PROMIS scores with legacy hip-specific PROs, and (3) quantify their floor and ceiling effects.

Study Design

Case series; Level of evidence, 4.

Methods

Consecutive patients who underwent primary GM repair between September 2017 and June 2021 with completed PROMIS at minimum 2-year follow-up were evaluated. The minimal clinically important difference, Patient Acceptable Symptom State, and substantial clinical benefit thresholds were defined for the PROMIS-PI and PROMIS-PF as well as for legacy PROs: Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Subscale (HOS-SS); modified Harris Hip Score (mHHS); 12-item International Hip Outcome Tool (iHOT-12); and the visual analog scale (VAS) for pain and satisfaction. Pearson correlations were performed between PROMIS scores and legacy PROs. Rates of floor and ceiling effects were quantified.

Results

Overall, 107 patients (81.7% follow-up compliance; mean age, 59.8 ± 8.8 years; 92.5% female; mean body mass index, 28.6 ± 6.3 kg/m2) were included in the analysis. GM tears were partial thickness in 56.1% of cases and treated endoscopically in 64.5% of cases. The minimal clinically important difference, Patient Acceptable Symptom State, and substantial clinical benefit thresholds, respectively, were as follows: PROMIS-PI (-4.6, 56.0, 52.6), PROMIS-PF (3.5, 42.7, 43.7), HOS-ADL (10.7, 68.2, 78.6), HOS-SS (16.5, 58.6, 60.6), mHHS (9.0, 64.3, 71.5), iHOT-12 (14.2, 63.6, 69.4), VAS pain (-16.1, 34.9, 28.1), and VAS satisfaction (not applicable, 70.9, 93.6). Moderate to strong correlations were observed between the PROMIS and legacy PROs. The PROMIS-PI showed a significant postoperative floor effect of 18.7%.

Conclusion

Study findings indicated that the PROMIS is effective for use in GM repair patients, given the moderate-to-strong correlations between the PROMIS and legacy hip-specific PROs, the mostly limited floor and ceiling effects, and large effect sizes. Use of PROMIS instead of legacy PROs may aid in limiting survey burden.

Outcomes and complications of hip arthroscopy for femoroacetabular impingement syndrome: A narrative review

Hip arthroscopy has emerged as the primary surgical intervention for Femoroacetabular Impingement Syndrome (FAIS), a common cause of hip pain in young adults, particularly athletes. This narrative review examines the long-term outcomes, complications, and debates surrounding arthroscopic management of FAIS. Key findings include sustained improvements in patient-reported outcomes, return to sport, and functional recovery, particularly in younger patients and those with cam-type FAIS. However, some patients may eventually require total hip arthroplasty (THA), highlighting the variability in long-term durability. Complications, though infrequent, remain a significant concern, with the most common being transient neuropathy due to prolonged traction, heterotopic ossification, and iatrogenic cartilage damage. Recent studies emphasize the importance of patient selection, with younger patients, those with capsular closure, and those without pre-existing osteoarthritis showing superior outcomes. Additionally, sex-based differences suggest females may experience higher complication rates, though they often report better functional improvements post-surgery. Areas of ongoing debate include the role of labral debridement versus repair, the optimal management of mixed-type FAIS, and the potential benefits of adjunctive procedures such as ligamentum teres debridement. Future research should focus on refining surgical techniques and identifying patient-specific factors to further optimize outcomes. Despite its complexities, hip arthroscopy remains an effective treatment for FAIS, though individualized treatment plans are crucial to addressing the unique needs of each patient. By synthesizing current evidence, this review aims to guide clinicians in optimizing FAIS management and identifying areas for future research.

Cartilage Defects Are Negatively Associated With Long-Term Hip Survivorship Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 10-Year Follow-Up

PURPOSE

To identify the timing and risk factors associated with secondary surgery following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year minimum follow-up.

METHODS

A prospectively collected clinical repository was evaluated for cases of primary hip arthroscopy for FAIS between January 2012 and February 2013 with minimum 10-year follow-up. Patients who underwent secondary surgery were propensity matched 1:4 to patients who did not undergo secondary surgery, controlling for age, sex, and body mass index (BMI). The groups were compared on demographics, radiographs, intraoperative findings, operative procedures, and patient-reported outcomes. A Kaplan-Meier survivorship curve was generated. Among the reoperation-free survivors, minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) achievement were recorded for Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and Visual Analog Scale for Pain (VAS Pain).

RESULTS

Twenty-four reoperation patients (67% female; age 40.1 ± 14.3 years; BMI 27.2 ± 5.5) were matched to 96 reoperation-free patients (62% female; age 37.0 ± 10.8 years; BMI 25.2 ± 4.7, P ≥ .111). Mean follow-up was 10.3 ± 0.2 years. No preoperative demographic differences were found between groups. The reoperation group showed more high-grade cartilage defects on the acetabulum and femoral head (33% vs 8%, P = .004; 29% vs 7%, P = .007). A bimodal distribution of time to reoperation was evidenced independent of the secondary surgery performed. Among the reoperation-free survivors, MCID and PASS achievement was as follows: HOS-ADL (69.1%, 62.1%), HOS-SS (69.9%, 74.4%), mHHS (73.3%, 58.1%), iHOT-12 (n/a, 63.8%), and VAS-Pain (80.2%, 62.6%).

CONCLUSIONS

Patients requiring reoperation following primary hip arthroscopy for FAIS demonstrated more severe cartilage defects and a bimodal distribution of time to reoperation.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Two-Year Outcomes of Primary Arthroscopic Surgery in Patients with Femoroacetabular Impingement: A Comparative Study of Labral Repair and Labral Reconstruction

BACKGROUND

Labral repair has become the preferred method for the arthroscopic treatment of acetabular labral tears that are associated with femoroacetabular impingement (FAI) resulting in pain and dysfunction. Labral reconstruction is performed mainly in revision hip arthroscopy but can be utilized in the primary setting for absent or calcified labra. The purpose of this study was to compare the minimum 2-year patient-reported outcomes (PROs) and risk of revision or conversion to arthroplasty between primary labral reconstruction and primary labral repair.

METHODS

Patients with FAI who underwent primary hip arthroscopy with labral repair or reconstruction performed by the senior author between 2006 and 2018 were identified from a prospectively enrolled patient outcome registry. Exclusion criteria included confounding injuries, dysplasia, prior ipsilateral hip surgery, or a joint space of <2 mm. Patients who were 18 to 80 years old were eligible for inclusion. Multiple regression with inverse propensity score weighting was conducted to estimate the average treatment effect in the treated (ATT) for labral reconstruction versus labral repair with respect to postoperative PROs and the likelihood of subsequent surgery (revision hip arthroscopy or conversion to arthroplasty). PRO end points included the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL), modified Harris hip score, Western Ontario and McMaster Universities Osteoarthritis Index total score (WOMAC), 12-Item Short Form Health Survey Physical Component Summary score (SF-12 PCS), and patient satisfaction.

RESULTS

A total of 150 hips undergoing primary labral reconstruction and 998 hips undergoing primary labral repair were included. The median follow-up time was 5.3 years in the reconstruction group and 5.8 years in the repair group. Compared with labral repair, labral reconstruction was associated with a higher risk of conversion to total hip arthroplasty (THA) (20% versus 7%; adjusted odds ratio, 3.2; 95% confidence interval [CI], 1.2 to 8.8; p = 0.024). Inverse propensity score-weighted multiple regression estimated a significant negative effect of labral reconstruction, relative to labral repair, on the postoperative values for the HOS-ADL (ATT, -3.3; 95% CI, -5.8 to -0.7; p = 0.012) and WOMAC (ATT, 2.6; 95% CI, 0.1 to 5.2; p = 0.044).

CONCLUSIONS

Compared with primary labral reconstruction, primary labral repair resulted in better postoperative HOS-ADL and WOMAC values and decreased conversion to THA. These findings were demonstrated in both the unadjusted group comparisons and multivariable modeling. These data support the use of labral repair in the primary setting of labral tears and the reservation of labral reconstruction for more advanced labral pathology or for revision cases.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in High-Level Athletes: A 10-Year Follow-up

Background

Arthroscopic treatment for femoroacetabular impingement syndrome (FAIS) has previously been reported to have favorable short-term results in high-level athletes. Less is known about long-term outcomes.

Purpose

To report outcomes 10 years after hip arthroscopy for FAIS in high-level athletes using validated patient-reported outcome measures (PROMs).

Study Design

Case series; Level of evidence, 4.

Methods

Patients who underwent hip arthroscopy between November 2011 and January 2013 were included in a local hip arthroscopy registry and completed preoperative PROMs. At 10-year follow-up, the same PROMs were completed. Inclusion criteria were age <40 years at time of surgery, no prior hip surgeries, and a pre-symptomatic Hip Sports Activity Scale (HSAS) level of 7 or 8. The exclusion criterion was total hip arthroplasty at follow-up. The PROMs included the international Hip Outcome Tool-12 items (iHOT-12), the Copenhagen Hip and Groin Outcome Score (HAGOS), visual analog scale (VAS) for overall hip function, European Quality of Life-5 Dimensions questionnaire (EQ-5D) and European Quality of Life-visual analog scale (EQ-VAS), HSAS, and a single question on patient satisfaction. The rates of patients achieving minimal important change and reporting Patient Acceptable Symptom State (PASS) were reported for HAGOS and iHOT-12. For iHOT-12, preoperative results were compared with 1, 5, and 10-year follow-ups.

Results

A total of 45 patients (34 men, 11 women; 70 hips; mean age 24.4 years at time of surgery) were included, with 77 patients eligible for inclusion. Significant improvements (P < .001) were seen at 10-year follow-up in all HAGOS subscales: Symptoms, Pain, Daily Activity, Sports, Physical Activity, Quality of Life (50.3 vs 78.6, 59.2 vs 86.8, 65.9 vs 88.8, 37.1 vs 81.1, 24.4 vs 81.1, 32.1 vs 79.3), iHOT-12 (40.1 vs 81.6), EQ-5D (0.59 vs 0.89), EQ-VAS (65.6 vs 80.4), and VAS for overall hip function (48 vs 79). For iHOT-12, the largest change was seen between preoperative and 1-year follow-up values, with consistent results over time. There was no statistically significant difference between HSAS levels preoperatively and at 10-year follow-up (HSAS level 4), with 24% of patients reporting a HSAS level 7 or 8 at the follow-up. Of the patients, 93% reported satisfaction with the surgery. PASS was achieved in 82% for iHOT-12, with a range of 76% to 91% for HAGOS subscales. Furthermore, 93% exceeded the minimal important change for iHOT-12, and a range of 67% to 84% for HAGOS.

Conclusion

In a high-level athletic population, significant improvements in long-term outcomes are reported after hip arthroscopy for FAIS, with patients reporting a high satisfaction rate. The results also show that the largest improvement occurs within the first postoperative year, with results being maintained for 10 years.

Surgical Hip Dislocation in the Era of Hip Arthroscopy Demonstrates High Survivorship and Improvements in Patient-reported Outcomes for Complex Femoroacetabular Impingement

BACKGROUND

Over the past decade, hip arthroscopy has become more commonly used in the treatment of patients with femoroacetabular impingement (FAI) as well as those with many other intra-articular hip pathologies. As such, the indications for open surgical hip dislocation have narrowed to include complex intra-articular and extra-articular bony morphologies and revision hip preservation. Although surgical hip dislocation has been established as an effective approach, previous research using contemporary indications has been limited primarily to smaller cohorts with short-term follow-up. Furthermore, factors associated with reoperation, conversion arthroplasty, and not achieving clinical improvement remain ambiguous.

QUESTIONS/PURPOSES

At a minimum of 2 years of follow-up in patients treated for FAI with surgical hip dislocation, (1) how much did patient-reported outcome measures (PROMs) improve, and what percentage of patients achieved the minimum clinically important difference (MCID) and patient-acceptable symptom state (PASS)? (2) What was the survivorship free from reoperation of the hip for any reason? (3) What was the survivorship free from conversion to arthroplasty (THA or hip resurfacing)?

METHODS

Between February 2011 and April 2021, 211 patients were treated at one academic institution with surgical dislocation and osteoplasty of the femoral head-neck junction or greater trochanter for FAI. Of these, patients with concomitant diagnoses including Legg-Calvé-Perthes disease, slipped capital femoral epiphysis, osteochondritis dissecans, a benign tumor, or another neurologic or metabolic disorder were excluded. This yielded 74% (156 of 211) of patients as potentially eligible. A further 12% (18 of 156) of patients without postoperative PROMs were excluded, and another 13% (21 of 156) were lost before the minimum study follow-up of 2 years, leaving 75% (117) for analysis at a median of 4.9 years (range 2 to 12 years) in this retrospective study. A total of 88% of the patients were women (103 of 117), and 40% (47 patients) underwent the procedure as a revision. All patients underwent surgical hip dislocation. Intraoperatively, 66% (77 of 117) of patients demonstrated cam impingement, and the remainder had either pincer impingement or combined cam and pincer; 82% (96 of 117) had some component of extra-articular impingement. To answer our first research question, we obtained PROM scores for the modified Harris hip score (mHHS) and international hip outcome tool 12 (iHOT-12) before surgery and at the most-recent follow-up from our longitudinally maintained institutional database, and we determined the percentage of patients who achieved the MCID or PASS. To answer our second research question, we calculated Kaplan-Meier survivorship free from any reoperation on the hip at 5.8 years (mean follow-up) after the index procedure. To answer our third research question, we calculated the Kaplan-Meier survivorship free from conversion to arthroplasty at 5.8 years. Using univariate logistic regression analysis, factors associated with meeting these defined endpoints were identified.

RESULTS

At a mean of 6 ± 3 years, the mHHS of patients treated with surgical hip dislocation for FAI who had not had previous surgery on the hip improved from 53 ± 15 to 85 ± 13 (mean difference 31 [95% confidence interval 27 to 36]; p < 0.01) and the mean iHOT-12 score improved from 25 ± 14 to 74 ± 24 (mean difference 49 [95% CI 42 to 56]; p < 0.01). At a mean of 5 ± 3 years, for patients with prior hip surgery, mHHS improved from 55 ± 13 to 79 ± 15 (mean difference 24 [95% CI 18 to 30]; p < 0.01) and iHOT-12 scores improved from 25 ± 16 to 66 ± 26 (mean difference 41 [95% CI 31 to 50]; p < 0.01). The proportion of patients who achieved the MCID for the mHHS was 87% (55 of 63) and 83% (33 of 40), while the proportion who achieved the PASS for the mHHS was 66% (46 of 70) and 51% (24 of 47) for primary and revision surgery, respectively. The proportion of patients who achieved the MCID for the iHOT-12 was 87% (53 of 61) and 83% (33 of 40), while the proportion who achieved the PASS for iHOT-12 was 68% (47 of 69) and 57% (26 of 46) for primary and revision surgery, respectively. Higher lateral center-edge angles (odds ratio 1.2 per 1° [95% CI 1.1 to 1.3]; p < 0.01), a lower acetabular version at 2:00 (OR 0.92 per 1° [95% CI 0.85 to 0.99]; p = 0.05), the absence of a labral tear (OR 0.21 [95% CI 0.06 to 0.79]; p = 0.02), a higher preoperative mHHS (OR 1.1 per 1 point [95% CI 1.02 to 1.2]; p < 0.01), and a higher preoperative iHOT-12 score (OR 1.1 per 1 point [95% CI 1.01 to 1.1]; p = 0.01) were associated with not achieving the MCID. In patients without a history of ipsilateral hip surgery, survivorship free from reoperation at 5.8 years after surgical hip dislocation was 90% (95% CI 82% to 98%). In the setting of prior ipsilateral hip surgery, survivorship free from reoperation at 5.8 years after surgical hip dislocation was 75% (95% CI 60% to 95%). No patients for whom surgical hip dislocation was their primary hip procedure underwent conversion to arthroplasty. Among the revision patient cohort, survivorship free from conversion to arthroplasty at 5.8 years after surgical hip dislocation was 97% (95% CI 91% to 100%).

CONCLUSION

Surgical hip dislocation effectively improves hip pain and function with high survivorship (free of reoperation or conversion to arthroplasty) for complex intra-articular and extra-articular FAI that is deemed less suitable for arthroscopic treatment, but when the procedure is used in patients who have had prior hip surgery, they should be told that revision surgery is a realistic possibility. If insufficient acetabular coverage is anticipated, acetabular reorientation osteotomy should be considered. Future studies should evaluate long-term survivorship and PROMs in larger patient cohorts, as well as identify other factors associated with reoperation and conversion to arthroplasty.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Patients Aged 40 Years and Older Demonstrate Durable and Comparable Results to Patients Aged Less Than 40 Years After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity Matched Study at Minimum 10-Year Follow-Up

PURPOSE

To compare clinical outcomes and rates of secondary surgery, including revision hip arthroscopy and conversion to total hip arthroplasty (THA), after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in patients ≥40 years of age at minimum 10-year follow-up compared with a propensity-matched control group of patients <40 years.

METHODS

A retrospective cohort study was performed for patients who underwent primary hip arthroscopy for FAIS between January 2012 and February 2013. Patients ≥40 years old were propensity matched in a 1:1 ratio by sex and body mass index to patients <40 years old. Patient-reported outcomes (PROs) including Hip Outcome Score for Activities of Daily Living and Sports-Specific subscales, modified Harris Hip, International Hip Outcome Tool-12, and Visual Analog Scale for Pain and Satisfaction were collected. Rates of minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) achievement at 10 years were evaluated and compared between groups. Rates of secondary surgery including revision hip arthroscopy and conversion to THA were evaluated. Gross survivorship between cohorts was evaluated using a Kaplan-Meier curve.

RESULTS

Fifty-three patients aged ≥40 (age 48.3 ± 5.8 years) were successfully matched to 53 patients aged <40 (age: 28.9 ± 7.2, <0.001). There were no other preoperative group differences regarding patient demographics, characteristics, or radiographic findings. Both groups demonstrated significant improvement regarding all PROs at a minimum of 10 years' follow-up (P < .001 for all). No significant difference was noted between cohorts regarding any delta (preoperative to 10-year postoperative) scores (P > .05 for all). High rates of MCID and PASS achievement were achieved in both cohorts, with no significant differences in any PRO measure (P > .05 for all). No significant differences in rates of complications (age ≥40: 2.0%, age <40: 7.7%, P = .363), rates of revision (age ≥40: 7.5%, age <40: 9.4%, P = .999), or conversion to THA (age ≥40: 13.2%, age <40: 3.8%, P = .161) were identified. On Kaplan-Meier analysis, no significant difference (P = .321) was demonstrated in overall gross survivorship between cohorts.

CONCLUSIONS

Patients with age ≥40 with FAIS undergoing primary hip arthroscopy demonstrated durable and comparable 10-year PRO and rates of MCID and PASS achievement compared with a propensity-matched cohort of age <40 counterparts.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Corticosteroid Injections Administered Within 4 Weeks Prior to Hip Arthroscopy Are Associated With Higher Rates of Postoperative Infection

PURPOSE

To evaluate the association between the timing of intra-articular hip corticosteroid injections and the risk of postoperative infection in patients undergoing hip arthroscopy.

METHODS

The 2010-2021 PearlDiver M157 administrative claims database was queried for patients who underwent hip arthroscopy. Patients who received intra-articular corticosteroid injections within 12 weeks prior to arthroscopy were matched 1:1 to patients who did not receive such injections based on age, sex, and Elixhauser Comorbidity Index, as well as the presence of diabetes mellitus, hypertension, obesity, and tobacco use. Those with injections prior to arthroscopy were subdivided based on having received injections within 12 weeks prior to surgery. To verify that the corticosteroid injections and surgical procedures were conducted in the hip joint, Current Procedural Terminology codes were used. By use of Current Procedural Terminology and International Classification of Diseases (ninth revision and tenth revision) coding, postoperative surgical-site infection after corticosteroid injection was evaluated. The impact of the timing of preoperative corticosteroid injections on the incidence of postoperative infection was evaluated using multivariable logistic regression analysis.

RESULTS

A total of 12,390 hip arthroscopy cases were identified, including 3,579 patients who received corticosteroid injections 0 to 4 weeks prior to surgery; 4,759, within 4 to 8 weeks prior to surgery; and 4,052, within 8 to 12 weeks prior to surgery. Compared with controls, patients who received corticosteroid injections within 0 to 4 weeks preoperatively had a significantly higher rate of surgical-site infection (odds ratio, 2.43; P = .0001). No significant differences in infection rates were observed at the later time intervals (4-8 weeks or 8-12 weeks). Furthermore, in comparison to controls, patients who received corticosteroid injections had a significantly higher rate of wound dehiscence (odds ratio, 1.84; P = .0007).

CONCLUSIONS

Intra-articular corticosteroid injections within 4 weeks prior to hip arthroscopy were significantly associated with increased surgical-site infection rates after hip arthroscopy surgery.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Ten-Year Outcomes in Patients Aged 40 Years and Older After Primary Arthroscopic Treatment of Femoroacetabular Impingement With Labral Repair

BACKGROUND

Arthroscopic labral repair has been shown to result in favorable short- and midterm outcomes; however, the durability of outcomes specifically in older patients remains underreported.

PURPOSE

To (1) report prospectively collected hip preservation rates and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in patients aged ≥40 years after primary hip arthroscopy with labral repair and (2) perform a matched analysis comparing patients aged ≥40 years with patients aged <40 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between February 2008 and December 2011. Patients aged ≥40 years who underwent labral repair were included. Preoperative and minimum 10-year follow-up scores were collected for multiple PROMs. Propensity score matching was utilized to compare these patients with a cohort of patients <40 years.

RESULTS

Of the 113 hips eligible, 91 hips (80.5%) on 85 patients (6 bilateral) had a minimum 10-year follow-up. There were 58 women (68%) and 27 men (32%) with a mean age and body mass index of 47.8 years and 25.8, respectively. The hip preservation rate for patients aged ≥40 years was 78%, with 20 patients requiring arthroplasty during the study period. There was significant improvement in all PROMs from baseline to minimum 10-year follow-up with high rates of achieving the minimal clinically important difference and Patient Acceptable Symptom State clinical outcome thresholds. In total, 69 patients aged ≥40 years were propensity matched to 107 patients <40 years. Patients ≥40 tended to have a lower hip preservation rate (81.2% vs 91.6%; P = .06), while patients in the younger cohort had significantly higher rates of secondary hip arthroscopy (14% vs 3%; P = .02). Improvement in PROMs was comparable between the groups.

CONCLUSION

Patients ≥40 years who underwent primary hip arthroscopy with labral repair demonstrated a hip preservation rate of 78%, significant and durable improvement in PROMs, and high rates of satisfaction at a minimum 10-year follow-up. Matched analysis with patients <40 years revealed comparable improvement in patient-reported outcomes between the 2 groups, with a tendency to a higher level of arthroplasty in patients ≥40 years.

Outcomes of Painful Hips After Hip Arthroscopy Surgery for Femoroacetabular Impingement

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

Patient Factors Influencing Outcomes at 12-Year Follow-up of Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement has increased in popularity since the early 2000s when it was first described, although only a few midterm follow-up studies have been published.

PURPOSE

To describe the outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement at a mean 12-year follow-up and to determine the risk factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The Non-Arthritic Hip Score (NAHS) and a radiographic evaluation were completed preoperatively and at midterm follow-up. Participants were divided into 2 groups according to their clinical evolution. The success group consisted of patients whose NAHS at the final follow-up was above the established Patient Acceptable Symptom State (PASS) threshold of 81.9, whereas patients who underwent a second surgical intervention or did not reach the PASS threshold at final follow-up were assigned to the failure group. These groups were compared to identify preoperative differences in demographic, pathological, and surgical factors.

RESULTS

A total of 95 hips were included, after 23 were lost to follow-up (80.5% follow-up). At a mean follow-up of 12.1 years (range, 9.2-16.0 years), 9 hips required total hip arthroplasty (9.5%), 5 required revision hip arthroscopy (5.3%), 29 did not achieve the NAHS PASS threshold (30.5%), and 52 achieved the NAHS PASS threshold (54.7%). The mean NAHS was 82.4 at final follow-up compared with 66.9 preoperatively (mean difference = 15.5; P < .001). Higher mean body mass index (24.9 vs 23.0; P = .030), older age (30.0 vs 27.2; P = .035), and inferior preoperative lateral joint space width (3.9 vs 4.4; P = .019) were associated with inferior prognosis in the failure group versus success group. Osteoarthritis progression was observed in 69.2% of the failure group and in 34.8% of the success group (P = .082). Labral ossification was observed in 78.3% of all patients, and its lateral projection length was statistically associated with failure (P = .015).

CONCLUSION

At a mean 12-year follow-up, hip arthroscopy for femoroacetabular impingement led to significant clinical improvement, with 55% PASS achievement. In total, 31% of patients were below the PASS threshold, 5% had revision arthroscopy, and only 9% had conversion to total hip arthroplasty for a 45% global failure rate. Increased body mass index, older age, and smaller preoperative lateral joint space width were significant negative prognostic factors. Postoperative degenerative changes were highly prevalent and demonstrated association with failure.

Comparison of Knotless Versus Knot-Tying Suture Anchors for Arthroscopic Repair of Hip Labral Tears

Background

Both knotless and knot-tying anchors are commonly employed in the arthroscopic repair of hip labral tears.

Purpose

To compare the midterm clinical results of arthroscopic hip labral repair using knot-tying versus knotless suture anchors.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent arthroscopic hip labral repair between January 2017 and January 2021 and who had at least 2 years of follow-up were included. The patients were divided into 2 groups based on the suture anchor type: a 2.9-mm knotless suture anchor (knotless group) or a 1.8-mm knot-tying suture anchor (knot-tying group). All patients underwent femoroplasty for cam lesions and acetabular rim trimming for pincer lesions. The modified Harris Hip Score (mHHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain were administered both preoperatively and postoperatively. The consistency of the outcome scores was assessed using the minimal clinically important difference and Patient Acceptable Symptom State. The statistical significance between groups was evaluated using the Mann-Whitney test and quantile-based analysis of variance.

Results

A total of 413 patients were included: 256 patients in the knotless group (median age, 35 years [interquartile range, 31-38 years]; median follow-up, 34 months) and 157 patients in the knot-tying group (median age, 34 years [interquartile range, 30-38 years]; median follow-up, 25 months). There were no significant differences in postoperative mHHS, HOS-ADL, or iHOT-12 scores between the 2 groups. However, there were significant differences, favoring the knotless group over the knot-tying group, in postoperative HOS-SSS (87 ± 2 vs 86 ± 1, respectively) and VAS pain (1 vs 2, respectively) scores (P < .0001 for both). Postoperative synovitis was found in significantly more patients in the knot-tying group than in the knotless group (17 vs 5, respectively; P = .01).

Conclusion

In this study, patients who underwent arthroscopic hip labral repair with knotless suture anchors had slightly better postoperative HOS-SSS and VAS pain scores and a lower incidence of postoperative synovitis compared with patients who underwent repair with knot-tying suture anchors.

Association of Patient Satisfaction 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome With Minimum 10-Year Patient-Reported Outcomes and Survivorship

BACKGROUND

Previous studies have shown that short-term outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) predict midterm outcomes, but a limited number of studies have evaluated whether short-term outcomes predict long-term outcomes and survivorship.

PURPOSE

To evaluate whether achieving clinically significant outcomes at 2 years after hip arthroscopy for FAIS can predict patient-reported outcomes (PROs) and survivorship at 10 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopy for FAIS between June 2012 and December 2012 with a minimum 10-year follow-up were identified. Using previously established thresholds, we classified patients who achieved the 2-year Patient Acceptable Symptom State (PASS) for the visual analog scale (VAS) for satisfaction as the high satisfaction group and patients who did not as the low satisfaction group. Minimum 10-year PROs were then compared between the groups, including scores for the Hip Outcome Score (HOS)-Activities of Daily Living and -Sports Specific, the modified Harris Hip Score, the VAS for pain, and the VAS for satisfaction. Reoperation-free survivorship was compared.

RESULTS

Of 120 eligible consecutive patients, 85 patients were included (70.8% follow-up rate), of whom 61.2% were female. The mean age was 34.0 ± 12.8 years, and the mean body mass index was 25.4 ± 4.6. Of the 85 patients, 29 (34.1%) did not achieve PASS for the VAS for satisfaction at 2 years postoperatively compared with 56 (65.9%) who did. The low satisfaction group had significantly worse acetabular chondral grades at the time of surgery (P = .008). At minimum 10-year follow-up, the high satisfaction group showed significantly better HOS-Activities of Daily Living, HOS-Sports Specific, modified Harris Hip Score, VAS pain, and VAS satisfaction scores (P≤ .031). Compared with the low satisfaction group, the high satisfaction group had a significantly lower rate of secondary surgery (1.8% vs 24.1%, respectively; P = .002).

CONCLUSION

Patients who achieved PASS for the VAS for satisfaction at 2 years after hip arthroscopy demonstrated superior minimum 10-year outcomes compared with patients who did not, including greater PRO scores and a higher survivorship rate. The high satisfaction group had lower grade acetabular cartilage damage at the time of surgery compared with those who did not achieve PASS for the VAS for satisfaction at 2 years.

Predictors of Clinical Outcomes After Hip Arthroscopy: 10-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have beneficial outcomes, there is a paucity of literature examining predictive factors of 10-year clinical outcomes.

PURPOSE

(1) To identify predictive factors of 10-year outcomes of hip arthroscopy and (2) to compare these factors with those found in 2-year and 5-year studies.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had a minimum 10-year follow-up on 2 patient-reported outcome measures: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Exclusion criteria included previous ipsilateral hip conditions. Using bivariate and multivariate analyses, that authors analyzed the effects of 37 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

Of the 883 patients who met the inclusion criteria, 734 (83.1%) had follow-up data. The mean follow-up time was 124.4 months (range, 120.0-153.1 months). Six variables were significant predictors of NAHS in both multivariate and bivariate analyses: revision status, body mass index (BMI), duration of symptoms, preoperative NAHS, age at onset of symptoms, and need for acetabular microfracture. Positive predictors of 10-year survivorship included acute injury and gluteus medius repair, while negative predictors included revision arthroscopy, Tönnis grade, acetabular inclination, iliopsoas fractional lengthening, and notchplasty.

CONCLUSION

Multiple predictive factors including age, BMI, revision status, and preoperative outcome scores were identified for long-term survivorship and functional outcomes. These may prove useful to clinicians in refining indications and guiding patients on expected outcomes of hip arthroscopy.

Bibliometric analysis of the acetabular labrum

The acetabular labrum (AL) plays a crucial role in the normal physiological functioning of the hip joint. This study aims to present an overview of the current status and research hotspots concerning the AL and to explore the field from a bibliometric perspective. A total of 1918 AL-related records published between January 1, 2000 and November 8, 2023 were gathered from the Web of Science Core Collection database. By utilizing tools such as HisCite, CiteSpace, VOSviewer, and the R package "bibliometrix," the regions, institutions, journals, authors, and keywords were analyzed to predict the latest trends in AL research. Global research interest and publication output related to this topic continues to escalate. The United States leads in international collaborations, number of publications, and citation frequency, underscoring its preeminent position in this field. The American Hip Institute emerged as the most prolific institution, making the greatest contribution to publications. Notably, Arthroscopy and the American Journal of Sports Medicine are the 2 most popular journals in this domain, accounting for 13.29% and 10.1% of publications, respectively, and were also found to be the most co-cited journals. Amongst authors, Benjamin G. Domb leads with 160 articles (8.35%), while Marc J. Philippon is the most frequently cited author. The keyword co-occurrence network showed 3 hot clusters, including "AL," "femoral acetabular impingement (FAI)," and "osteoarthritis." In addition, "survivorship," "FAI," and "patient-reported outcomes" were identified as trending topics for future exploration. This study represents the first comprehensive bibliometric analysis, summarizing the present state and future trends in AL research. The findings serve as a valuable resource for scholars, offering practical insights into key information within the field and identifying potential research frontiers and emerging directions in the near future.

Subpectineal obturator nerve block reduces opioid consumption after hip arthroscopy: a triple-blind, randomized, placebo-controlled trial

BACKGROUND

Hip arthroscopy causes severe pain during the first few hours in the postoperative care unit. This is probably due to the intraoperative stretching of the hip joint capsule. Pain relief requires high doses of opioids which may prolong recovery and may cause opioid-related adverse events.The majority of hip joint capsule nociceptors are located anteriorly. The obturator nerve innervates the anteromedial part of the hip joint capsule. We hypothesized that a subpectineal obturator nerve block using 15 ml bupivacaine 5 mg/mL with added epinephrine 5 μg/mL would reduce the opioid consumption after hip arthroscopy.

METHODS

40 ambulatory hip arthroscopy patients were enrolled in this randomized, triple-blind controlled trial. All patients were allocated to a preoperative active or placebo subpectineal obturator nerve block. The primary outcome was opioid consumption for the first 3 hours in the postanesthesia care unit. Secondary outcomes were pain, nausea, and hip adductor strength.

RESULTS

34 patients were analyzed for the primary outcome. The mean intravenous morphine equivalent consumption in the subpectineal obturator nerve block group was 11.9 mg vs 19.7 mg in the placebo group (p<0.001). The hip adductor strength was significantly reduced in the active group. No other intergroup differences were observed regarding the secondary outcomes.

CONCLUSION

We found a significant reduction in the opioid consumption for patients receiving an active subpectineal obturator nerve block. The postoperative intravenous morphine equivalent reduction the first painful 3 hours was reduced by 40% for patients receiving a subpectineal obturator nerve block in this randomized, triple-blind trial.

TRIAL REGISTRATION NUMBER

EudraCT database 2021-006575-42.

The Use of Combined Hip Arthroscopy and Periacetabular Osteotomy for Hip Dysplasia Is Increasing and Has Low Complication Rates

Purpose

To analyze the annual use of hip arthroscopy (HA) and Bernese periacetabular osteotomy (PAO) for the treatment of hip dysplasia (HD), as well as postoperative outcomes, including ipsilateral reoperations.

Methods

International Classification of Diseases, Ninth and Tenth Revision, codes were used to query the PearlDiver Mariner database from January 2010 through January 2022 to identify patients aged 10 to 59 years who had a presenting diagnosis of HD and subsequently underwent (1) HA; (2) PAO; or (3) combined HA and PAO (HA-PAO, defined as PAO on the same day or within 28 days after HA). We analyzed annual rates for each treatment, as well as rates of postoperative emergency visits, readmissions, and 5-year ipsilateral secondary operations (determined via Kaplan-Meier analysis).

Results

There were 32,068 patients who underwent surgical treatment of HD. For HA, PAO, and HA-PAO, there were 29,700, 2,083, and 285 patients, respectively. All operations had the greatest percent-increase from 2015 to 2016. HA and HA-PAO peaked in 2021, whereas PAO peaked in 2019. For HA, PAO, and HA-PAO, most cases were performed in female patients and patients aged 30 to 49 years, 10 to 19 years, and 10 to 29 years, respectively. The 5-year incidence of ipsilateral secondary operations, which include revision HA, PAO, or conversion to total hip arthroplasty, was 9.2% (95% confidence interval 8.6%-9.8%) in the HA group and 6.5% (95% confidence interval 4.1%-8.8%) in the PAO group. Combining HA with PAO resulted in so few secondary operations that Kaplan-Meier analysis was infeasible. The PAO cohort had the greatest 30-day emergency visit and 90-day readmission rates, with infection as the most common cause for readmission.

Conclusions

HA is more frequently performed than PAO for hip dysplasia. HA-PAO is increasing at the greatest rate, demonstrating fewer complications and reoperations.

Level of Evidence

Level III, retrospective comparative trial.

Hip arthroscopy is an effective treatment for high-level female athletes

OBJECTIVES

This study aimed to assess the outcomes of hip arthroscopic surgery in high-level female athletes diagnosed with femoroacetabular impingement (FAI) compared to those with lower levels of sports activity. Additionally, we investigated the effectiveness of patient-reported outcomes (PROs) and the potential ceiling effect as a lack of sensitivity in detecting clinically statistically significant changes in high-level female athletes due to high baseline scores.

METHODS

We conducted a retrospective analysis of prospectively collected data from female patients who underwent hip arthroscopy for FAI between January 2016 and August 2022 with a minimum 1-year follow-up. Patients were categorised into two groups: high-level athletes (group A) and low sports activity level (group B). Various PROs, visual analogue scales for pain, and patient satisfaction were assessed preoperatively and postoperatively. Return to sports (RTS) rates were determined based on the patient's reported ability to return to their previous level of sports activity. The minimally clinically important differences (MCIDs) and the Patient-Acceptable Symptomatic State (PASS) analyses were used to evaluate the clinical impact of the Hip Outcome Score-Sport Subscale (HOS-SSS).

RESULTS

A total of 11 high-level female athletes were included in group A, and 22 were included in the low sports activity level group B. Both groups showed significant improvements in PROs, with no significant differences between them. RTS rates were lower in high-level athletes (63.6%) than in low sports activity patients (85.7%). Visual analogue scales for pain improved significantly in both groups. Patient satisfaction was high in both groups, with a median score of 9. The HOS-SSS showed no ceiling effect, and the MCID and PASS analyses indicated that a high proportion of patients in both groups achieved clinically relevant improvement in HOS-SSS.

CONCLUSION

Hip arthroscopic surgery is effective for FAI treatment in high-level female athletes, with outcomes similar to those in patients with lower sports activity levels. The absence of a ceiling effect in sports-related outcomes suggests that PROs can detect clinically significant changes in high-level female athletes. Although RTS rates were lower in high-level athletes, this difference was not significant. These findings underscore the value of using PROs to evaluate outcomes in female athletes with different sports-activity levels.

LEVEL OF EVIDENCE

IV.

Preoperative Paralabral Cysts Predict More Significant Chondral Damage but Not 2-Year Functional Outcomes Following Arthroscopic Labral Repair

PURPOSE

To investigate whether paralabral cysts identified incidentally on preoperative magnetic resonance imaging/arthrography predict 2-year functional outcomes after arthroscopic acetabular labral repair.

METHODS

Prospectively collected data for patients undergoing primary hip arthroscopy by a single surgeon from 2014 to 2020 were retrospectively reviewed. Included patients were ≥18 years and completed baseline patient-reported outcome measures (PROMs) with additional follow-up at 3, 6, 12, and 24 months. Exclusion criteria were labral debridement, hip dysplasia, advanced hip osteoarthritis (Tönnis > 1), or previous ipsilateral hip surgery. Patients were stratified based on the presence of paralabral cysts identified on magnetic resonance imaging/arthrography. Primary outcomes were International Hip Outcome Tool and modified Harris Hip Score. Secondary outcomes included other PROMs and the visual analog pain scale. Outcomes were compared between cohorts using linear mixed-effects models and Fisher's exact tests. Sensitivity analyses accounted for preoperative PROMs, nonlinear improvement trajectories, and relevant baseline characteristics.

RESULTS

Of the 182 included hips (47.8% female; mean ± standard deviation age, 36.9 ± 11.4), 30 (16.4%) had paralabral cysts. During the 2-year study period, there were no significant differences between patients with and without paralabral cysts in terms of International Hip Outcome Tool scores (weighted difference = 1.60; 95% confidence interval [CI], -5.09, 8.28; P = .64), modified Harris Hip Scores (weighted difference = 0.56; 95% CI, -4.16, 5.28; P = .82), or any secondary outcomes (except for HOS-Sports Subscale at 3 months [mean difference = -11.85; 95% CI, -22.85, -0.84; P = .035]). Furthermore, there were no significant differences in clinically meaningful outcomes (P > .05 for all), revision rates (P > .99), or conversion to total hip arthroplasty between cohorts (P > .99). These results held across all sensitivity analyses.

CONCLUSIONS

Although preoperative paralabral cysts were associated with worse cam impingement and more severe chondral damage observed intraoperatively, they did not predict 2-year functional outcomes or clinically meaningful improvements, suggesting that incidentally discovered paralabral cysts are not a contraindication for arthroscopic labral repair.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

BACKGROUND

Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD.

PURPOSE

To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups.

RESULTS

In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835).

CONCLUSION

Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.

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

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement (FAI) and symptomatic labral tears confers short- to midterm benefits, yet further long-term evidence is needed. Moreover, despite the physiological and biomechanical significance of the chondrolabral junction (CLJ), the clinical implications of damage to this transition zone remain understudied.

PURPOSE

To (1) report minimum 8-year survivorship and patient-reported outcome measures after hip arthroscopy for FAI and (2) characterize associations between outcomes and patient characteristics (age, body mass index, sex), pathological parameters (Tönnis angle, alpha angle, type of FAI, CLJ breakdown), and procedures performed (labral management, FAI treatment, microfracture).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

This retrospective cohort study included patients who underwent primary hip arthroscopy for symptomatic labral tears secondary to FAI by a single surgeon between 2002 and 2013. All patients were ≥18 years of age with minimum 8-year follow-up and available preoperative radiographs. The primary outcome was conversion to total hip arthroplasty (THA), and secondary outcomes included revision arthroscopy, patient-reported outcome measures, and patient satisfaction. CLJ breakdown was assessed using the Beck classification. Kaplan-Meier estimates and weighted Cox regression were used to estimate 10-year survivorship (no conversion to THA) and identify risk factors associated with THA conversion.

RESULTS

In this study of 174 hips (50.6% female; mean age, 37.8 ± 11.2 years) with mean follow-up of 11.1 ± 2.5 years, the 10-year survivorship rate was 81.6% (95% CI, 75.9%-87.7%). Conversion to THA occurred at a mean 4.7 ± 3.8 years postoperatively. Unadjusted analyses revealed several variables significantly associated with THA conversion, including older age; higher body mass index; higher Tönnis grade; labral debridement; and advanced breakdown of the CLJ, labrum, or articular cartilage. Survivorship at 10 years was inferior in patients exhibiting severe (43.6%; 95% CI, 31.9%-59.7%) versus mild (97.9%; 95% CI, 95.1%-100%) breakdown of the CLJ (P < .001). Multivariable analysis identified worsening CLJ breakdown (weighted hazard ratio per 1-unit increase, 6.41; 95% CI, 3.11-13.24), older age (1.09; 95% CI, 1.04-1.14), and higher Tönnis grade (4.59; 95% CI, 2.13-9.90) as independent negative prognosticators (P < .001 for all).

CONCLUSION

Although most patients achieved favorable minimum 8-year outcomes, several pre- and intraoperative factors were associated with THA conversion; of these, worse CLJ breakdown, higher Tönnis grade, and older age were the strongest predictors.

Editorial Commentary: A Majority of Athletes Return to Sport After Hip Arthroscopy and Show Mid-Term Durability Regardless of High Impact Activity

At least 3 of 4 athletes will not only return to sport after hip arthroscopy but also maintain durability in their sport regardless of high-impact activity. Hoping our injured athletes can return to sport after their injury would prove an insufficient answer to our injured patients' expectations of a mathematically precise answer. As it turns out, Mathematical Hope exists as a term to describe the way we calculate probability. Because scientific research has shed light on the great outcomes that can be obtained from the arthroscopic treatment of a joint, we are now able to witness amazing comeback stories in the news and incredible outcomes from short- to long-term in scientific journals. Hip arthroscopy has now been supported by numerous research publications, turning our doubts into certainties, as high return to sport rates at high levels of performance are increasingly published.

Long-term Outcomes of Primary Hip Arthroscopy: Multicenter Analysis at Minimum 10-Year Follow-up With Attention to Labral and Capsular Management

BACKGROUND

Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited.

PURPOSE

To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes-including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations.

RESULTS

A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation-including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P≤ .039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P = .006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P = .085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P = .033).

CONCLUSION

At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation-including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair.

Increasing Hip Arthroscopy Case Volume Is Associated With Increased Risk for Revision Surgery but Not Conversion to Total Hip Arthroplasty or 90-Day Hospitalizations: A Cross-Sectional Analysis of 468 Surgeons

PURPOSE

To analyze the effects of surgeon-specific factors, including case volume, career duration, fellowship training, practice type, and region of practice, on rates of 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations following hip arthroscopy.

METHODS

The PearlDiver Mariner Database was used to query patients undergoing hip arthroscopy between 2015 and 2018. Surgeons performing these procedures were identified, and surgeon-specific demographics and variables were collected from publicly available data. Patients were followed for 2 years to assess for reoperations, including revision hip arthroscopy and conversion to THA, as well as 90-day hospitalizations, including emergency department visits and hospital readmissions. International Classification of Diseases, Tenth Revision codes were used to track the laterality of revision hip procedures. Associations between surgeon-specific factors and postoperative outcomes were assessed through univariate and multivariate analyses.

RESULTS

In total, 20,834 patients underwent hip arthroscopy procedures by 468 surgeons. Multivariate analysis with logistic regression adjusted for patient-related factors (age, sex, obesity, Charlson Comorbidity Index, and smoking status) identified increasing surgeon case volume to be associated with increased risk for 2-year revision hip arthroscopy (P < .001), but not 2-year conversion to THA or 90-day hospitalizations. Nonsports medicine fellowship-trained surgeons were associated with greater risk for 2-year THA conversion (P < .001) and 90-day hospital readmissions (P < .01). Surgeons practicing in an academic setting demonstrated greater risk for 90-day hospital readmissions (P < .001). Surgeons practicing in the West region of the United States were more likely to incur 2-year revision hip arthroscopy procedures compared to surgeons in the South, Midwest or Northeast (P < .001).

CONCLUSIONS

Increasing surgeon hip arthroscopy case volume is associated with an increased risk for 2-year revision hip arthroscopy but not conversion to THA or 90-day hospitalizations. Further, non-sports medicine fellowship-trained surgeons were associated with higher risk for 2-year THA conversion after hip arthroscopy.

LEVEL OF EVIDENCE

Level III, retrospective cohort analysis.

A Superolateral Cam Lesion Location Increases Odds of Total Hip Arthroplasty 5 Years After Hip Arthroscopy

PURPOSE

To determine if radiographic cam location is associated with hip survivorship and postoperative patient-reported outcomes (PROs) at 5-year follow-up.

METHODS

We conducted a review of prospectively collected data of patients with cam lesions who underwent hip arthroscopy for femoroacetabular impingement syndrome. Cam lesions were categorized into 3 locations: superolateral, anterolateral, or anterior. Conversion to total hip arthroplasty (THA), revision rates, and reoperation rates were assessed. Patient-reported outcome measures, including modified Harris Hip Scores (mHHS) and Non-Arthritic Hip Scores (NAHS), were collected preoperatively and at 5-year follow-up.

RESULTS

Of the 156-patients, 125 met the final criteria (80.1%). Mean age was 41.1 ± 12.7 years. Seventy-one patients (56.8%) had superolateral cam lesions, 41 (32.8%) had anterolateral lesions, and 13 (10.4%) had anterior lesions. Revision rates within 5 years were 7.7% for anterior, 24.4% for anterolateral, and 14.1% for superolateral lesions; conversions to THAs were 15.4% for anterior), 7.3% for anterolateral, and 8.5% for superolateral. Reoperations were 23.1% for anterior, 29.3% for anterolateral, and 21.1% for superolateral. The superolateral cohort was younger than the anterior and anterolateral cohorts (anterior, 46.6 ± 12.2 years; anterolateral, 44.7 ± 12.2 years; superolateral, 38.1 ± 12.3 years; P = .006). Multivariable analysis showed the anterolateral group was significantly predictive of lower odds of undergoing THA compared to the superolateral group (odds ratio, 0.01; 95% CI, <0.01-0.72; P = .03). There were no differences in the 5-year improvement in mHHS (anterior, 32.4; anterolateral, 36.8; superolateral, 33.0; P = .29) or NAHS (anterior, 34.8; anterolateral, 39.0; superolateral, 37.3; P = .65).

CONCLUSIONS

A superolateral cam lesion increases the odds of conversion to THA within 5 years of hip arthroscopy compared to those with anterolateral lesions on multivariable analysis. Those with superolateral lesions were significantly younger compared to those with anterior or anterolateral lesions. Cam lesion location did not affect improvement in PROs at 5-year follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

Pericapsular Nerve Group Block Leads to Small but Consistent Reductions in Pain Between 18 and 24 Hours Postoperatively in Hip Arthroscopy for Femoroacetabular Impingement Surgery: A Prospective, Randomized Controlled Clinical Trial

PURPOSE

To investigate whether the use of a pericapsular nerve group (PENG) block would reduce perioperative pain after arthroscopic therapy for femoroacetabular impingement syndrome (FAIS) and to examine opioid requirements and occurrence of postoperative nausea and vomiting (PONV).

METHODS

Between May 2022 and October 2022, patients (N = 68) undergoing arthroscopic surgery for FAIS were randomly allocated into 2 groups. The first group received an ultrasound-guided PENG preoperatively with 20 mL of 0.375% ropivacaine and standardized postoperative oral medication. The second group received a sham block preoperatively with 20 mL of 0.9% saline and standardized postoperative oral medication. The primary end point was pain scores (visual analog score [VAS], 0-10) during the first 24 hours postoperatively. To quantify clinical significance of outcome achievement for the VAS pain score, the minimal clinically important difference (MCID) was calculated using the half standard deviation method. The incidence of PONV as well as opioid usage (converted to morphine equivalent) within the first 24 hours were secondary outcomes.

RESULTS

Randomization and permission were successfully obtained from 68 participants. From the fifteenth postoperative hour, the PENG group reported significantly less postoperative pain than the control group (24th postoperative hour: VAS pain PENG group 1.3 ± 0.9 [0-3]; 95% confidence interval {CI} 0.4-1.2 vs the VAS pain control group 2.4 ± 1.6 [0-5]; 95% CI 1.4-4.7; P = .009). The VAS pain score threshold for achieving the MCID at 24 hours postoperative was defined as a decrease of 1.1. 27 patients (79%) in the PENG group and 22 patients (65%) in the control group were able to achieve MCID (P = .009). Opioid dosage and postoperative nausea did not differ significantly between groups (P = .987 and P = .655, respectively). Concomitant complications such as falls, hematomas, or weakened muscles did not occur in either group.

CONCLUSIONS

According to this study, a PENG block minimally reduced pain after arthroscopic treatment for FAIS between the 18th and 24th postoperative hours. The PENG group achieved significantly more often the pain VAS MCID. However, there was no proof that the PENG group consumed fewer opioids than the control group. Overall, PONV was found at a low and comparable rate.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Improved Functional Outcomes of Combined Hip Arthroscopy and Periacetabular Osteotomy at Minimum 2-Year Follow-Up

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at minimum 2-year follow-up after combined hip arthroscopy and periacetabular osteotomy (PAO) performed in the setting of a single anesthetic event.

METHODS

Patients who underwent combined hip arthroscopy (M.J.P.) and PAO (J.M.M.) between January 2017 and June 2020 were identified. Preoperative and minimum 2-year postoperative PROs including Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport, modified Harris Hip Score (mHHS), Western Ontario and McMaster Universities Osteoarthritis Index, 12-Item Short Form Survey Mental Component Scores (SF-12 MCS), and 12-Item Short Form Survey Physical Component Score were collected and compared in addition to revision rate, conversion to total hip arthroplasty (THA), and patient satisfaction.

RESULTS

Twenty-four of 29 patients (83%) eligible for the study were available for 2-year minimum follow-up with a median follow-up time of 2.5 years (range, 2.0-5.0). There were 19 females and 5 males with mean age of 31 ± 12 years. Mean preoperative lateral center edge angle was 20° ± 5° and alpha angle was 71° ± 11°. One patient underwent reoperation for removal of a symptomatic iliac crest screw at 11.7 months after operation. Two patients, a 33-year-old woman and a 37-year-old man, were converted to THA at 2.6 and 1.3 years, respectively, following the combined procedure. Both patients had a Tönnis grade of 1 on radiographs, as well as bipolar Outerbridge grade III/IV defects requiring microfracture of the acetabulum. For patients who did not convert to THA (n = 22), there was significant improvement from before to after surgery for all scores (P < .05) except SF-12 MCS. The minimal clinically significant difference and patient-acceptable symptom state rates for HOS-ADL, HOS-Sport, and mHHS were 72%, 82%, 86%, and 95%, 91%, and 95%, respectively. Median patient satisfaction was 10 (range, 4 to 10).

CONCLUSIONS

Single-stage combined hip arthroscopy with periacetabular osteotomy for patients with symptomatic hip dysplasia results in improvement in PROs and arthroplasty free survivorship of 92% at median 2.5 year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Outcomes of Isolated Endoscopic Gluteal Tendon Repair Compared With Concomitant Endoscopic Gluteal Tendon Repair and Arthroscopic Hip Labral Repair: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background

Both gluteal and labral tears are common sources of hip pain, but no studies have evaluated how concomitant arthroscopic labral repair and correction of femoroacetabular impingement syndrome (FAIS) affect outcomes after endoscopic gluteus/minimus repair.

Purpose

(1) To compare patient-reported outcomes (PROs) and clinically significant outcomes achievements between patients who underwent endoscopic gluteus medius/minimus and arthroscopic hip labral repair with correction of FAIS versus endoscopic gluteus medius/minimus repair without labral repair and (2) to define threshold scores required to achieve the minimal clinically important difference (MCID) and the Patient Acceptable Symptom State (PASS) for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool, and visual analog scale for pain in these patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Patients who underwent primary endoscopic gluteus medius/minimus repair between 2012 and 2020 were identified. Those who underwent concomitant arthroscopic labral repair and correction of FAIS with femoroplasty or acetabuloplasty as indicated were propensity matched in a 1 to 1 ratio by sex, age, and body mass index to patients who underwent gluteus medius/minimus repair without labral repair. Patients who completed the study PROs were assessed preoperatively and at 2 years postoperatively. Threshold scores required to achieve the MCID and PASS thresholds were calculated.

Results

A total of 32 patients who underwent simultaneous gluteal and labral repair (G+L) were matched to 32 patients who underwent gluteal repair without labral repair (G); 75% of patients in the G cohort underwent labral debridement, while 25% in this cohort received no labral treatment. A significant difference was observed between groups in preoperative mHHS scores (G+L, 54.4 ± 12.9 vs G, 46.3 ± 14; P = .048) but no differences in any other PRO scores (P≥ .207). The MCID/PASS thresholds were as follows: Hip Outcome Score-Activities of Daily Living (11.14/83.82), Hip Outcome Score-Sports Specific (16.07/59.72), mHHS (11.47/70.95), 12-item international Hip Outcome Tool (13.73/45.49), and visual analog scale for pain (14.30/22). There were no significant differences in MCID or PASS achievement rates between the 2 groups (P≥ .108).

Conclusion

Patients who underwent combined G+L demonstrated comparable PROs and clinically significant outcomes achievement rates to patients who underwent G, highlighting sustained successful outcomes for patients with gluteal tendon pathology and concomitant FAIS and labral tears.

Assessment of Risk Factors and Rate of Conversion to Total Hip Arthroplasty Within 2 Years After Hip Arthroscopy Utilizing a Large Database of Commercially Insured Patients in the United States

Background

The conversion rate of hip arthroscopy (HA) to total hip arthroplasty (THA) has been reported to be as high as 10%. Despite identifying factors that increase the risk of conversion, current studies do not stratify patients by type of arthroscopic procedure.

Purpose/Hypothesis

To analyze the rate and predictors of conversion to THA within 2 years after HA. It was hypothesized that osteoarthritis (OA) and increased patient age would negatively affect the survivorship of HA.

Study Design

Cohort study; Evidence level, 3.

Methods

The IBM MarketScan database was utilized to identify patients who underwent HA and converted to THA within 2 years at inpatient and outpatient facilities between 2013 and 2017. Patients were split into 3 procedure cohorts as follows: (1) femoroacetabular osteoplasty (FAO), which included treatment for femoroacetabular impingement; (2) isolated debridement; and (3) isolated labral repair. Cohort characteristics were compared using standardized differences. Conversion rates between the 3 cohorts were compared using chi-square tests. The relationship between age and conversion was assessed using linear regression. Predictors of conversion were analyzed using multivariable logistic regression. The median time to conversion was estimated using Kaplan-Meier tests.

Results

A total of 5048 patients were identified, and the rates of conversion to THA were 12.86% for isolated debridement, 8.67% for isolated labral repair, and 6.76% for FAO (standardized difference, 0.138). The isolated labral repair cohort had the shortest median time to conversion (isolated labral repair, 10.88 months; isolated debridement, 10.98 months; and FAO, 11.9 months [P = .034). For patients >50 years, isolated debridement had the highest rate of conversion at 18.8%. The conversion rate increased linearly with age. Factors that increased the odds of conversion to THA were OA, having an isolated debridement procedure, and older patient age (P < .05).

Conclusion

Older patients and those with preexisting OA of the hip were at a significantly increased risk of failing HA and requiring a total hip replacement within 2 years of the index procedure. Younger patients were at low risk of requiring a conversion procedure no matter which arthroscopic procedure was performed.

Acetabular Labral Reconstruction Does Not Demonstrate Superior Biomechanical Properties Compared to Labral Repair or Intact Native Labrum but Is Superior to Labral Excision: A Systematic Review of Cadaveric Studies

PURPOSE

To systematically review and compare biomechanical properties of labral reconstruction to labral repair, intact native labrum, and labral excision in cadaveric studies.

METHODS

A search of the PubMed and Embase databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and checklist. Cadaveric studies focused on hip biomechanics related to intact labrum, labral repair, labral reconstruction, labral augmentation, and labral excision were included. Investigated parameters included biomechanical data measures, such as distraction force, distance to suction seal rupture, peak negative pressure, contact area, and fluid efflux. Review articles, duplicates, technique reports, case reports, opinion articles, articles written in a language other than English, clinical studies focusing on patient-reported outcomes, studies performed in animals, and articles with no abstract available were also excluded.

RESULTS

Fourteen cadaveric biomechanical studies were included that compared labral reconstruction to labral repair (4 studies), labral reconstruction to labral excision (4 studies); and evaluation of distractive force of the labrum (3 studies), the distance to suction seal rupture (3 studies), fluid dynamics (2 studies), displacement at peak force (1 study), and stability ratio (1 study). Data pooling was not performed because of methodological heterogenicity of the studies. Labral reconstruction did not outperform labral repair in restoring the hip suction seal or any other biomechanical property. Labral repair significantly prevented greater fluid efflux when compared to labral reconstruction. Labral repair and reconstruction improved the distractive stability of the hip fluid seal from the labral tear and labral excision stage, respectively. Furthermore, labral reconstruction demonstrated to have better biomechanical properties than labral excision.

CONCLUSIONS

In cadaveric studies, labral repair or intact native labrum was biomechanically more superior than labral reconstruction; however, labral reconstruction can restore acetabular labral biomechanical properties and was biomechanically superior to labral excision.

CLINICAL RELEVANCE

In cadaveric models, labral repair outperforms segmental labral reconstruction in preserving the hip suction seal; nonetheless, segmental labral reconstruction biomechanically outperforms labral excision at time 0.

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage

BACKGROUND

Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS).

PURPOSE

To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups.

RESULTS

In total, 94 patients (mean age, 41.9 ± 14.2 years) were included with a mean follow-up duration of 6.1 ± 0.9 years. Of these patients, 40.4% had no acetabular overcoverage, 36.2% had lateral overcoverage, and 23.4% had global overcoverage. There was no difference between groups with respect to percentage of patients who underwent reoperation for either revision arthroscopy or conversion to total hip arthroplasty (28.9% for the normal acetabular coverage group, 29.4% for the lateral overcoverage group, and 31.8% for the global overcoverage group; P = .971). Among patients for whom primary hip arthroscopy did not fail, there was no difference in 5-year functional outcomes between groups. Postoperative LCEA >40° (β = -13.3; 95% CI, -24.1 to -2.6; P = .016), female sex (β = -14.5; 95% CI, -22.7 to -6.2; P = .001), and higher body mass index (β = -1.9; 95% CI, -2.8 to -1.0; P < .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score.

CONCLUSION

There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.