Surgical Treatment of Femoroacetabular Impingement: Hip Arthroscopy Versus Surgical Hip Dislocation: A Propensity-Matched Analysis

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.

Development and implementation of a roadmap for improving quality of care in prearthritic hip disease: A journey over 20 years

The understanding and treatment of prearthritic hip disease has evolved remarkably over the past 20 years. The principal investigator and the multicenter Academic Network of Conservational Hip Outcomes Research (ANCHOR) group have had a key role in improving the quality of care for these patients suffering from the three most common prearthritic conditions: femoroacetabular impingement, developmental dysplasia of the hip, and residual Legg-Calve-Perthes Disease. We aim to demonstrate that based on the six quality of care dimensions as defined by Donabedian, our 20-year academic journey has markedly improved the quality of care for young patients with prearthritic hip disease.

The Definition of Failure in Hip Arthroscopy May Include Factors Outside of Reoperation: A Systematic Review

Purpose

To perform a systematic review about the varying definitions of "failure" of hip arthroscopy (HA) in the current literature and to provide a recommendation for the standardization of defining failure of HA.

Methods

A systematic search of electronic databases was conducted to identity Level I-IV clinical studies on HA failure published between January 2016 and July 2021 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Inclusion criteria consisted of studies of patients who underwent an arthroscopic hip procedure and included a definition of failure. Studies with patients who underwent open hip procedures and non-full-text articles were excluded.

Results

Of 1,290 titles, 85 (6.6%) met inclusion criteria and were analyzed in this review. The most common definition of HA failure used was the need for any subsequent ipsilateral hip surgery (80/85, 94.1%). Among studies that noted reoperation as a cause for failure, conversion to total hip arthroplasty was most frequently cited (66/85, 77.6%) followed by any other reoperation on the ipsilateral hip, including repeat HA, hip resurfacing, and hip periacetabular osteotomy (65/85, 76.5%). Multiple studies used subjective patient-reported outcomes, with use of the modified Harris Hip Score being the most common (17/85, 20%).

Conclusions

There are numerous definitions of the term "failure" of HA used by authors in the peer-reviewed literature. A standardized definition of HA failure should be multifactorial. It may include any unplanned subsequent procedures; patient-reported outcomes with emphasis on minimal clinically important difference, substantial clinical benefit, and/or patient acceptable symptom state values; and the inability to return to normal function or sports.

Level of Evidence

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

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.

Risk Factors for Suboptimal Outcome of FAI Surgery in the Adolescent Patient

BACKGROUND

Surgical treatment for adolescent patients with femoroacetabular impingement (FAI) is increasing. The purpose of this study was to determine the clinical outcomes of FAI surgery in a multicenter cohort of adolescent patients and to identify predictors of suboptimal outcomes.

METHODS

One hundred twenty-six adolescent hips (114 patients < 18 years of age) undergoing surgery for symptomatic FAI were studied from a larger multicenter cohort. The group included 74 (58.7%) female and 52 male hips (41.3%) with a mean age of 16.1 (range 11.3 to 17.8). Clinical outcomes included the modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (5 domains), and University of California Los Angeles activity score. Failure was defined as revision surgery or clinical failure (inability to reach minimally clinical important differences or patient acceptable symptoms state for the mHHS). Statistical analysis was used to identify factors significantly associated with failure.

RESULTS

There was clinically important improvement in all patient-reported outcomes for the overall group, but an 18.3% failure rate. This included a revision rate of 8.7%. Females were significantly more likely than males to be classified as a failure (25.7 vs. 7.7%, P =0.01), in part because of lower preoperative mHHS (59.1 vs. 67.0, P < 0.001). Mild cam deformity (alpha angle <55 degrees) was present in 42.5% of female hips compared with 17.3% male hips. Higher alpha angles were inversely correlated with failure. Alpha angles >63 have a failure rate of 8.3%, between 55 and 63 degrees, 12.0% failure rate, and <55 degrees (mild cam) failure rate of 37.5%. Patients who participated in athletics had a 10.3% failure rate compared with nonathletes at 25.0% ( P =0.03, RR (relative risk) 2.4).

CONCLUSIONS

Adolescent patients undergoing surgical treatment for FAI generally demonstrate significant improvement. However, female sex, mild cam deformities, and lack of sports participation are independently associated with higher failure rates. These factors should be considered in surgical decision-making and during patient counseling.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Comparison of Gait and Functional Outcomes Between Open and Arthroscopic Treatment of Adolescent and Young Adult Femoroacetabular Impingement

BACKGROUND

Management of femoroacetabular impingement (FAI) through an arthroscopic or surgical hip dislocation (SHD) approach has been shown to have similar clinical success and patient-reported outcomes. However, there are limited data comparing functional outcomes. The purpose of this study was to compare gait and functional outcomes of adolescent/young adult patients with FAI treated by either an arthroscopic or open SHD approach.

METHODS

We identified prospectively enrolled adolescent/young adult patients (≤20 years old) who underwent surgical treatment for FAI through an SHD or arthroscopic approach. Participants were evaluated in a movement science lab preoperatively and postoperatively (minimum 8 months postoperatively) with barefoot walking and a 30-second single-limb balance trial on the affected side. Participants also completed the Harris Hip Score at the same timepoints. Differences from preoperative to postoperative were determined using a paired-samples t test for each surgical technique, and differences between the SHD and arthroscopic groups were determined using an independent samples t test (α=0.05).

RESULTS

Fifty-five participants (42F, 16.2±1.4 y) were tested and grouped by surgical intervention. The SHD and arthroscopy groups consisted of 28 and 27 participants, respectively, with no significant difference between the SHD and arthroscopic cohorts in age (16.4±1.2 vs. 15.9±1.5 y, respectively, P =0.218) or sex distribution (78.6% vs. 74.1% females, respectively, P =0.75). Each group demonstrated significant postoperative improvement in Harris Hip Score (SHD: 64.8±16.4 to 81.8±17.8; arthroscopy: 57.0±16.7 to 84.7±19.7; preoperatively to postoperatively, respectively, both P <0.001). During gait, increased maximum hip flexion was observed following surgical intervention for the SHD group (32.3±5.7 vs. 36.1±5.2, P =0.003). No other clinically significant changes were detected in the SHD or arthroscopic groups preoperatively to postoperatively in trunk, pelvis, or hip kinematics in the coronal plane. During the balance task, neither cohort demonstrated markers of clinically significant abductor dysfunction. However, post operatively, the arthroscopy group was able to balance longer than the SHD group (18.8±7.8 vs. 14.2±2.7 s, respectively, P =0.008), although no differences were detected in trunk or pelvis position in the coronal plane during balance.

CONCLUSIONS

Both open SHD and arthroscopic treatment of FAI resulted in improved clinical outcomes with no clinically significant abductor dysfunction 1 year post operatively. However, further study is needed to determine whether more dynamic tasks can potentially elicit subtle differences between the groups.

LEVELS OF EVIDENCE

Level II-prospective study.

Soft Tissue Cam Impingement in Adolescents: MRI Reveals Impingement Lesions Underappreciated on Radiographs

BACKGROUND

Femoroacetabular impingement (FAI) has been described as repetitive and abnormal contact between a structurally abnormal proximal femur (cam) and/or acetabulum (pincer), occurring during the terminal range of motion of the hip. While cam and pincer lesions have traditionally been defined as osseous abnormalities, there may be a subset of adolescent patients whose impingement is primarily soft tissue (nonosseous). The existence of a nonosseous cam lesion in adolescents with FAI has not been well described.

PURPOSE

To identify and characterize a series of adolescent patients with nonosseous (soft cam) FAI identified on magnetic resonance imaging (MRI) and compare these patients' clinical presentation and outcome with those of a cohort with primary osseous cam FAI in the same age group.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A prospective institutional registry of patients with symptomatic FAI was reviewed. Patients were included if they had an MRI scan and a lateral radiograph of the hip (45° Dunn or frog) at a baseline visit. On MRI, the anterolateral femoral head was evaluated using radial, coronal, sagittal, or axial oblique sequences. A soft cam lesion was identified by the presence of soft tissue thickening of ≥2 mm at the anterolateral femoral head-neck junction. An alpha angle was measured on MRI scans and radiographs when a lesion was identified. The cohort with soft cam lesions was reviewed and findings and outcomes were compared with those of a cohort with osseous cam lesions. Continuous variables were first examined for normality, and then nonparametric tests-such as the Kruskal-Wallis test-were considered. The change between pre- and postoperative patient-reported outcomes (PROs) was described by mean and standard deviation and evaluated with an independent-samples t test.

RESULTS

A total of 31 (9.3%) of 332 hips (mean age, 16.4 years [range 13.1-19.6 years]; women, 83.9%) were identified with a soft tissue impingment lesion on MRI at the femoral head-neck junction between the 12 and 3 o'clock positions. These lesions demonstrated a thickened perichondral ring (71%), periosteal thickening (26%), or a cartilaginous epiphyseal extension (3%). The mean alpha angle on MRI was greater than on radiographs (63.5°± 7.9° vs 51.3°± 7.9°; P < .0001). A total of 22 patients (71%) with soft impingement underwent hip preservation surgery. When compared with patients in the osseous cohort who also underwent surgical management, both groups showed similar significant improvements from pre- to postoperatively (soft: modified Harris Hip Score [mHHS], 26.9 ± 18.2; Hip disability and Osteoarthritis Outcome Score [HOOS], 31.4 ± 22.9; osseous: mHHS, 22.8 ± 20.8; HOOS, 27.4 ± 20.1; P < .0001), with a mean follow-up of 3.4 years (range, 1-7 years) in the soft cam cohort and 3 years (1-10.1 years) in the osseous cam cohort.

CONCLUSION

Clinicians should be aware of nonosseous or soft cam lesions that cause impingement in adolescent patients without an obvious osseous cam on radiographs. MRI is required to detect these soft cam lesions. When nonoperative treatment fails, the PROs in these patients after operative management are comparable with those in patients with osseous cam lesions. Further research is needed to determine whether the soft cam precedes an osseous cam or whether it is a separate entity.

The Relationship Between Pelvic Tilt and Clinical Outcomes After Hip Preservation Surgery in Femoroacetabular Impingement Syndrome and Hip Dysplasia

Pelvic tilt is thought to be a compensatory mechanism in hip pathology, specifically in patients with femoroacetabular impingement syndrome (FAIS) and hip dysplasia. This study investigated the relationship between preoperative pelvic tilt and postoperative outcomes in patients undergoing hip preservation surgery for FAIS or hip dysplasia. We reviewed a prospective hip preservation database for demographic, radiographic, and outcome data for 89 patients who underwent hip preservation surgery with a primary diagnosis of FAIS or dysplasia from 2016 to 2020. Pelvic tilt was assessed on the standing anteroposterior radiograph with the pubic symphysis to sacroiliac joint (PS-SI) distance measurement. The International Hip Outcome Tool 12 (iHOT-12), Hip Outcome Score, Harris Hip Score, UCLA activity score, and European Quality of Life-Visual Analog Scale were used to assess hip function and pain preoperatively and postoperatively. The mean pelvic tilt (PS-SI distance) was 86.4±18.3 mm for the FAIS group and 96.2±15.1 mm for the dysplasia group. The statistical analysis demonstrated a positive relationship between pelvic tilt and change in iHOT-12 score (rs=0.262, P=.019) for all 89 patients with hip pathology and, separately, a trend toward significance for the 42 patients with FAIS (rs=0.330, P=.056). No other significant relationships were observed. The improvement in iHOT-12 score was greater for patients with more anterior tilt and less for patients with posterior pelvic tilt, regardless of underlying hip etiology. These results provide intriguing insights into an initial investigation on pelvic tilt in patients undergoing hip preservation surgery. Further investigation is necessary to assess pelvic tilt preoperatively and postoperatively, spinal parameters, and longer-term outcomes. [Orthopedics. 2023;46(6):e341-e346.].

Team Approach: Hip Preservation Surgery

The evaluation and treatment of adolescents and young adults with hip pain has seen tremendous growth over the past 20 years. Labral tears are well established as a common cause of hip pain but often occur because of underlying bony abnormalities. Femoroacetabular impingement (FAI) and acetabular dysplasia are now well-established causes of hip osteoarthritis and are increasingly treated in the prearthritic stage in hopes of improving symptoms and prolonging the longevity of the native hip. Beyond FAI and acetabular dysplasia, this patient population can present with a complex and variable group of underlying conditions that need to be taken into account. Expertise in the conservative management of this population, including physical therapy, is valuable to maximize the success. Preoperative, surgical, and postoperative decision-making and care in this population is complex and evolving. A comprehensive, multidisciplinary approach to the care of this patient population has been used for over 20 years by our institution with great success. The purpose of this article is to review the "team-based approach" necessary for successful management of the spectrum of adolescent and young adult hip disorders.

Relationships between self-perceived and clinical expression of pain and function differ based on the underlying pathology of the human hip

BACKGROUND

Patient-reported outcomes are commonly used to assess patient symptoms. The effect of specific hip pathology on relationships between perceived and objectively measured symptoms remains unclear. The purpose of this study was to evaluate differences of function and pain in patients with FAIS and DDH, to assess the correlation between perceived and objective function, and to determine the influence of pain on measures of function.

METHODS

This prospective cross-sectional study included 35 pre-operative patients (60% female) with femoroacetabular impingement syndrome (FAIS) and 37 pre-operative patients (92% female) with developmental dysplasia of the hip (DDH). Objectively measured function (6-min walk [6MWT], single leg hop [SLHT], Biodex sway [BST], hip abduction strength [HABST], and STAR excursion balance reach [STAR] tests), patient-reported function (UCLA Activity, Hip Outcome Score [HOS], Short Form 12 [SF-12], and Hip Disability and Osteoarthritis Outcome Score [HOOS]), and patient-reported pain (HOOS Pain, visual analogue scale (VAS), and a pain location scale) were collected during a pre-surgical clinic visit. Between-group comparisons of patient scores were performed using Wilcoxon Rank-Sum tests. Within-group correlations were analyzed using Spearman's rank correlation coefficients. Statistical correlation strength was defined as low (r =  ± 0.1-0.3), moderate (r =  ± 0.3-0.5) and strong (r >  ± 0.5).

RESULTS

Patients with DDH reported greater pain and lower function compared to patients with FAIS. 6MWT distance was moderately-to-strongly correlated with a number of patient-reported measures of function (FAIS: r = 0.37 to 0.62, DDH: r = 0.36 to 0.55). Additionally, in patients with DDH, SLHT distance was well correlated with patient reported function (r = 0.37 to 0.60). Correlations between patient-reported pain and objectively measured function were sparse in both patient groups. In patients with FAIS, only 6MWT distance and HOOS Pain (r = -0.53) were significantly correlated. In patients with DDH, 6MWT distance was significantly correlated with VAS Average (r = -0.52) and Best (r = -0.53) pain.

CONCLUSION

Pain is greater and function is lower in patients with DDH compared to patients with FAIS. Moreover, the relationship between pain and function differs between patient groups. Understanding these differences is valuable for informing treatment decisions. We recommend these insights be incorporated within the clinical continuum of care, particularly during evaluation and selection of surgical and therapeutic interventions.

The Impact of Age on Clinical Outcomes of Acetabular Microfracture During FAI Surgery

BACKGROUND

Full-thickness acetabular cartilage lesions are common findings during primary surgical treatment of femoroacetabular impingement (FAI).

PURPOSE

To evaluate clinical outcomes after acetabular microfracture performed during FAI surgery in a prospective, multicenter cohort.

STUDY DESIGN

Cohort Study; Level of evidence, 3.

METHODS

Patients with FAI who had failed nonoperative management were prospectively enrolled in a multicenter cohort. Preoperative and postoperative (mean follow-up, 4.3 years) patient-reported outcome measures were obtained with a follow-up rate of 81.6% (621/761 hips), including 54 patients who underwent acetabular microfracture. Patient characteristics, radiographic parameters, intraoperative disease severity, and operative procedures were analyzed. Propensity matching using linear regression was used to match 54 hips with microfracture to 162 control hips (1:3) to control for confounding variables. Subanalyses of hips ≤35 and >35 years of age with propensity matching were also performed.

RESULTS

Patients who underwent acetabular microfracture were more likely to be male (81.8% vs 40.9%; P < .001), be older in age (35.0 vs 29.9 years; P = .001), have a higher body mass index (27.2 vs 25.0; P = .001), and have a greater alpha angle (69.6° vs 62.3°; P < .001) compared with the nonmicrofracture cohort (n = 533). After propensity matching to control for covariates, patients treated with microfracture displayed no differences in the modified Harris Hip Score or Hip Disability and Osteoarthritis Outcome Score (P = .22-.95) but were more likely to undergo total hip arthroplasty (THA) (13% [7/54] compared with 4% [6/162] in the control group; P = .002), and age >35 years was associated with conversion to THA after microfracture. Microfracture performed at or before 35 years of age portended good outcomes with no significant risk of conversion to THA at the most recent follow-up.

CONCLUSION

Microfracture of acetabular cartilage defects appears to be safe and associated with reliably improved short- to mid-term results in younger patients; modified expectations should be realized when full-thickness chondral lesions are identified in patients >35 years of age.

Surgical Hip Dislocation in Pediatric and Adolescent Patients

LEVEL OF EVIDENCE

V, Expert opinion.

Radiographic Predictors of Reoperation in Adolescents Undergoing Hip Preservation Surgery for Femoroacetabular Impingement

BACKGROUND

Femoroacetabular impingement (FAI) is a condition caused by repetitive abutment of a morphologically abnormal proximal femur and/or acetabulum that may result in chondral and labral pathology. An understanding of radiographic parameters associated with successful primary surgery has not been well established.

PURPOSE

To determine preoperative radiographic parameters that predict reoperation for FAI and correlate radiographic measurements with outcomes in these patients.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

A prospectively collected institutional registry of adolescent patients (age, <19 years) who underwent surgery for FAI (arthroscopic/open) was reviewed. Preoperative standing anteroposterior pelvic radiographs were analyzed for femoroepiphyseal acetabular roof (FEAR) index, as well as lateral center-edge angle (LCEA) and alpha, Tönnis, and Sharp angles. Patient-reported outcomes (PROs) (modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score) were analyzed preoperatively and at 1- and 2-year followup. Radiographic indication of risk for reoperation was evaluated using receiver operating characteristic (ROC) analysis. Spearman correlation was calculated between radiographic measurements and PROs at 2 years postoperatively.

RESULTS

A total of 81 patients (91 hips) underwent primary surgery (57 surgical dislocations vs 34 arthroscopies) for FAI. The mean age at time of primary operation was 16.23 years (range, 10.4-19.6 years) (73.6% female). Eleven hips (12.1%) underwent reoperation at a mean of 20.6 months from primary surgery. The LCEA, FEAR index, Tönnis angle, and Sharp angle before index surgery were significantly different (P < .05) between patients who underwent reoperation and those who did not. ROC analysis indicated that LCEA <22°, FEAR index >-8.7°, Tönnis angle >6.0°, and Sharp angle >44° were predictors for increased risk of reoperation. Using the cutoff values from the ROC analysis in this series, 43% of patients with an LCEA ≤22° had a repeat procedure, while only 8% of those with an LCEA >22° had a repeat procedure. Similar trends were seen with the other aforementioned acetabular radiographic measurements (FEAR index, Tönnis angle, Sharp angle). Patients who did not require a reoperation demonstrated significant improvement in all PRO categories from their preoperative to 2-year postoperative visits (P < .0001).

CONCLUSION

In patients undergoing treatment for FAI, a reoperation was associated with radiographic signs of hip dysplasia, indicating that patients with a shallower acetabulum are at risk for a repeat operation.

Durable Outcomes After Hip Labral Reconstruction at Minimum 5-Year Follow-Up: A Systematic Review

PURPOSE

To systematically review and report the mid- to long-term patient reported outcomes (PROs) following hip labral reconstruction.

METHODS

A literature search of the Pubmed, Embase, and Cochrane Library databases was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for clinical studies reporting mid- to long-term PROs at minimum five year follow-up following arthroscopic hip labral reconstruction. A quality assessment was performed using the Methodological Index of Non-Randomized Studies (MINORS) grading system. Data collection included study characteristics, demographics, indications, radiographic metrics, perioperative findings, surgical technique, baseline and most recent PROs, and subsequent surgeries.

RESULTS

Four studies met inclusion criteria, with 182 hips (age range, 27.9 to 38.7 years) undergoing labral reconstruction in primary and revision hip surgery with minimum five year follow-up. There were three level III studies and one level IV study, with an average MINORS score of 16.6. All studies cited labral tissue characteristics as a factor for surgical indications, including the quality and/or size of the labrum. Three studies performed segmental labral reconstructions, while another study utilized a circumferential technique. Varying grafts were selected, including hamstring autograft/allograft, ligamentum teres autograft, iliotibial band autograft, and tensor fascia lata autograft. All studies demonstrated improved PROs from baseline to most recent follow-up, with four studies reporting modified Harris Hip Score (mHHS) values that increased from baseline (range, 58.9 to 66.8) to most recent follow-up (range, 80.1 to 86.3). After labral reconstruction, rates of revision arthroscopy ranged from 4.8% to 13.3% and conversion to total hip arthroplasty ranged from 1.6% to 27%.

CONCLUSION

Improved PROs were observed in all studies at minimum 5-year follow-up, suggesting that labral reconstruction can offer durable results beyond short-term follow-up. While surgical indications for all studies included labral tissue characteristics, differing graft selection and surgical techniques were utilized across studies, limiting the ability to determine an optimal treatment approach.

Open and arthroscopic management of femoroacetabular impingement: a review of current concepts

Femoroacetabular impingement (FAI) is a common femoral and/or acetabular abnormality that can cause progressive damage to the hip and osteoarthritis. FAI can be the result of femoral head/neck overgrowth, acetabular overgrowth or both femoral and acetabular abnormalities, resulting in a loss of native hip biomechanics and pain upon hip flexion and rotation. Radiographic evidence can include loss of sphericity of the femoral neck (cam impingement) and/or acetabular retroversion with focal or global overcoverage (pincer impingement). Operative intervention is indicated in symptomatic patients after failed conservative management with radiographic evidence of impingement and minimal arthritic changes of the hip, with the goal of restoring normal hip biomechanics and reducing pain. This is done by correcting the femoral head-neck relationship to the acetabulum through femoral and/or acetabular osteoplasty and treatment of concomitant hip pathology. In pincer impingement cases with small lunate surfaces, reverse periacetabular osteotomy is indicated as acetabular osteoplasty can decrease an already small articular surface. While surgical dislocation is regarded as the traditional gold standard, hip arthroscopy has become widely utilized in recent years. Studies comparing both open surgery and arthroscopy have shown comparable long-term pain reduction and improvements in clinical measures of hip function, as well as similar conversion rates to total hip arthroplasty. However, arthroscopy has trended toward earlier improvement, quicker recovery and faster return to sports. The purpose of this study was to review the recent literature on open and arthroscopic management of FAI.

Does Femoral Osteoplasty Improve Long-term Clinical Outcomes and Survivorship of Hip Arthroscopy? A 15-Year Minimum Follow-up Study

BACKGROUND

Although femoral osteoplasty is common practice in treating cam-type femoroacetabular impingement (FAI), long-term data are lacking that support the ability of this procedure to optimize outcomes and alter natural history.

PURPOSE

To compare long-term clinical outcomes and survivorship of treatment for symptomatic FAI via arthroscopic correction of labral or chondral pathology with and without femoral osteoplasty.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective cohort study was performed across 2 consecutive cohorts of patients with isolated cam-type FAI who underwent hip arthroscopic treatment of labral or chondral pathology without femoral osteoplasty (HS group) or with femoral osteoplasty (HS-OST group). These unique cohorts were established at a distinct transition time in our practice before and after adoption of femoral osteoplasty for treatment of FAI. Clinical outcomes were measured using the modified Harris Hip Score (mHHS). Kaplan-Meier analysis was used to assess for total hip arthroplasty (THA)-free and reoperation-free survivorship.

RESULTS

The final HS group included 17 hips followed for 19.7 ± 1.2 years, and the final HS-OST group included 23 hips followed for 16.0 ± 0.6 years. No significant patient or morphological differences were found between groups. Compared with the HS group, the HS-OST group had significantly higher final mHHS (82.7 vs 64.7 for HS-OST vs HS, respectively; P = .002) and mHHS improvement (18.4 vs 6.1; P = .02). The HS-OST group also had significantly greater 15-year THA-free survivorship versus the HS group (78% vs 41%, respectively; P = .02) and reoperation-free survivorship (78% vs 29%; P = .003).

CONCLUSION

This study demonstrated superior long-term clinical outcomes and survivorship with combined arthroscopy and femoral osteoplasty compared with hip arthroscopy alone. These long-term data strongly support the practice of femoral osteoplasty in patients with cam FAI morphologies and suggest that this treatment alters the natural history of FAI at long-term follow-up.

Ten-year outcome following surgical treatment of femoroacetabular impingement

Aims

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

Methods

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

Results

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

Conclusion

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

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

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Open Hip Abductor Repair Hitting the Sack-Abductor Tendon Repair Significantly Improves Sleep Quality

PURPOSE

To (1) describe the prevalence of abnormal sleep quality in patients with hip abductor tears (HAT), to (2) determine whether sleep quality improves after open HAT repair, and to (3) to report clinical short-term outcomes in patients undergoing open HAT repair.

METHODS

The data of 28 patients (29 hips) who underwant open HAT repair were prospectively analyzed at midterm follow-up. The Pittsburgh Sleep Quality Index (PSQI), modified Harris Hip Score (mHHS), the University of California, Los Angeles activity scale (UCLA), and Visual Analog Scale (VAS) for pain were determined via questionnaire. Paired t-tests were applied to compare preoperative and post-operative Patient-reported Outcome Measures (PROMs). Logistic regression was performed to determine the association between PSQI improvement achievement and demographic variables (laterality, sex, age, body-mass-index (BMI), and preoperative mHHS). The minimal clinically important difference (MCID) was calculated for the mHHS.

RESULTS

A total of 28 patients were included. Four patients (14.3%) suffered post-operative complications after open HAT repair. The predominance of patients was female (77.4%), with a mean age of 60 ± 13 years. The average follow-up was 30.35 ± 16.62 months. Preoperatively, 27 (96.4%) patients experienced poor sleep quality (PSQI > 5); at follow-up, 7 (25%) patients experienced poor sleep quality. Univariate logistical regression analysis demonstrated no significant association between preoperative demographic data and achieving postoperative PSQI < 5. The MCID of mHHS was calculated to be 12.5. Overall, 90% of patients achieved MCID for mHHS.

CONCLUSION

Preoperative sleep quality was impaired in 96.4% of HAT patients (PSQI > 5). However, these patients showed an improvement in sleep disturbances after open HAT repair in the early postoperative period. Ninety percent of patients showed significant improvements in mHHS and achieved the corresponding MCID.

LEVEL OF EVIDENCE

Case series; Level IV.

Good Outcome Scores and Low Conversion Rate to THA 10 Years After Hip Arthroscopy for the Treatment of Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of symptomatic femoroacetabular impingement (FAI) has promising short-term to mid-term results. In addition to treating acute pain or impaired function, the goal of hip-preserving surgery is to achieve a lasting improvement of hip function and to prevent the development of osteoarthritis. Long-term results are necessary to evaluate the effectiveness of surgical treatment and to further improve results by identifying factors associated with conversion to THA.

QUESTIONS/PURPOSES

(1) How do the Merle d'Aubigné-Postel scores change from before surgery to follow-up of at least 10 years in patients undergoing hip arthroscopy for the treatment of FAI? (2) What is the cumulative 10-year survival rate of hips with the endpoints of conversion to THA or a Merle d'Aubigné-Postel score less than 15? (3) Which factors are associated with conversion to THA?

METHODS

Between 2003 and 2008, we treated 63 patients (65 hips) for symptomatic FAI with hip arthroscopy at our institution. During that period, the indications for using arthroscopy were correction of anterior cam morphology and anterolateral rim trimming with debridement or reattachment of the labrum. We excluded patients who were younger than 16 years and those who had previous trauma or surgery of the hip. Based on that, 60 patients (62 hips) were eligible. A further 17% (10 of 60) of patients were excluded because the treatment was purely symptomatic without treatment of cam- and/or pincer-type morphology. Of the 50 patients (52 hips) included in the study, 2% (1) of patients were lost before the minimum study follow-up of 10 years, leaving 49 patients (51 hips) for analysis. The median (range) follow-up was 11 years (10 to 17). The median age at surgery was 33 years (16 to 63). Ninety percent (45 of 50) of patients were women. Of the 52 hips, 75% (39 of 52) underwent cam resection (femoral offset correction), 8% (4 of 52) underwent acetabular rim trimming, and 17% (9 of 52) had both procedures. Additionally, in 35% (18 of 52) of hips the labrum was debrided, in 31% (16 of 52) it was resected, and in 10% (5 of 52) of hips the labrum was reattached. The primary clinical outcome measurements were conversion to THA and the Merle d'Aubigné-Postel score. Kaplan-Meier survivorship and Cox regression analyses were performed with endpoints being conversion to THA or Merle d'Aubigné-Postel score less than 15 points.

RESULTS

The clinical result at 10 years of follow-up was good. The median improvement of the Merle d'Aubigné-Postel score was 3 points (interquartile range 2 to 4), to a median score at last follow-up of 17 points (range 10 to 18). The cumulative 10-year survival rate was 92% (95% CI 85% to 99%) with the endpoints of conversion to THA or Merle d'Aubigné-Postel score less than 15. Factors associated with conversion to THA were each year of advancing age at the time of surgery (hazard ratio 1.1 [95% CI 1.0 to 1.3]; p = 0.01) and preoperative Tönnis Grade 1 compared with Tönnis Grade 0 (no sign of arthritis; HR 17 [95% CI 1.8 to 166]; p = 0.01).

CONCLUSION

In this series, more than 90% of patients retained their native hips and reported good patient-reported outcome scores at least 10 years after arthroscopic treatment of symptomatic FAI. Younger patients fared better in this series, as did hips without signs of osteoarthritis. Future studies with prospective comparisons of treatment groups are needed to determine how best to treat complex impingement morphologies.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Sex Differences in Clinical Outcomes Following Surgical Treatment of Femoroacetabular Impingement

BACKGROUND

Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates.

METHODS

Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively.

RESULTS

Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes.

CONCLUSIONS

Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation.

LEVEL OF EVIDENCE

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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