Hip arthroscopy in obese, a successful combination?

Delayed hip arthroscopy for femoroacetabular impingement syndrome does not increase revision but does increase rates of chronic opiate use

Introduction

In recent years, the utilization of hip arthroscopy to treat femoroacetabular impingement syndrome (FAIS) has increased due to its low complication rates, positive impact on patient-reported outcomes (PROs), and association with faster rehabilitation. Despite this, there are high rates of revision and conversion to total hip arthroplasty (THA) in some of these patients. It is unclear whether time from initial FAIS diagnosis to surgery is a risk factor for poor outcomes. In this study, we examined the relationship between timing of hip arthroscopy for FAIS and rates of 2-year revision hip procedures, 2-year conversion to total hip arthroplasty (THA), post-operative medical complications, and opioid prescriptions.

Methods

This is a retrospective cohort study utilizing the PearlDiver database. Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes were used to identify patients who had surgery for FAIS with minimum 2 years follow-up available. Patients were stratified by 3-month intervals into 5 groups based on time from diagnosis of FAIS to hip arthroscopy. Multivariate logistic regression was performed to determine factors independently associated with continued opiate use and subsequent surgeries.

Results

A total of 14,677 patients were included in the study. The 2-year rate of revision hip arthroscopy was 4.2%. As time from diagnosis to surgery increased, even in multivariate regression analysis, there was a higher risk of filling an opioid prescription 90 days after surgery (P < 0.001). Regression analysis demonstrated that timing of surgery was not associated with 2-year revision hip arthroscopy or conversion to THA. Age, sex, obesity, and tobacco use were significant predictors of revision hip arthroscopy and conversion to THA (p < 0.001).

Conclusion

There is no significant difference between timing of surgery for FAIS and odds of revision or conversion to THA. Prolonged opiate use after hip arthroscopy was significantly higher as duration from initial FAIS diagnosis to surgery increased. Age, sex, obesity, and tobacco use are significant predictors for revision, conversion to THA, and continued opiate prescriptions.

Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review

PURPOSE

To review outcomes of patients with low-back pathology undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome.

METHODS

The PubMed, Cochrane Trials, and Scopus databases were queried in June 2022 to conduct this systematic review using the following terms: ("hip" OR "femoroacetabular impingement") AND ("arthroscopy" OR "arthroscopic") AND ("spine" OR "lumbar" OR "sacral" OR "hip-spine" OR "back") AND ("outcomes"). Articles were included if they reported on patient-reported outcomes (PROs) and/or clinical benefit of patients undergoing hip arthroscopy with concomitant low-back pathology. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Case reports, opinion articles, review articles, and technique articles were excluded from this study. Forest plots were created to analyze preoperative and postoperative outcomes among patients with low-back pathology.

RESULTS

Fourteen studies were included in the review. There were 750 hips with low-back pathology and FAI (hip-spine syndrome) and 1,800 hips with only FAI (no hip-spine syndrome). All 14 studies reported PROs. In 4 studies in the group with hip-spine syndrome and 8 studies in the group with FAI without low-back pathology, the respective cohorts were reported to achieve the minimal clinically important difference in at least 1 PRO at a rate of 80%. Eight studies reported that patients with low-back pathology were associated with inferior outcomes or clinical benefit compared with patients without low-back pathology.

CONCLUSIONS

Patients undergoing primary hip arthroscopy with concomitant low-back pathology can expect favorable outcomes, but outcomes are superior in patients undergoing hip arthroscopy for FAI alone compared with FAI with concomitant low-back pathology.

LEVEL OF EVIDENCE

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

Hip arthroscopy versus total hip arthroplasty-A study on patients with obesity above 40 years of age

Patients older than 40 years with a body-mass-index (BMI) >30 kg/m2 , a femoroacetabular-impingement (FAI) and little cartilage damage are a challenge for hip surgeons. Hip-arthroscopy (HAS) or conservative therapy until a total hip arthroplasty (THA) is needed are possible treatments. Our research purpose was to compare the clinical results and complication/reoperation rate after HAS and THA in patients with obesity over 40 years. This retrospective study includes a consecutive series of patients with obesity (BMI >30 kg/m2 ) who underwent HAS (19 hips) and THA (37 hips) over 40 years of age between 2007 and 2013 at our institution with a minimum of 12-months follow-up. Outcome measures were WOMAC (Western Ontario und McMaster Universities Arthritis Index), subjective-hip-value (SHV), residual complaints and the reoperation rate. Patient data and scores were collected pre-operative, 12 months post-operatively and at the last follow-up. Both groups showed a comparable age (mean 48 years). Regarding SHV-Scores the THA-group shows continuous significant improvements. Reaching 87% (range 50%-100%), the HAS-group showed in case of the SHV no significant change after 1 year and an improvement from preoperative to the last follow-up reaching 72% (range 30%-100%) at the last follow-up. Residual groin pain was significant higher in the HAS-group. Two deep infections (5.4%) requiring reoperations were reported in the THA-group. The conversion rate to THA after a mean time of 60 months was 26% (5 of 19). Patients with obesity over 40 years demonstrated inferior SHV, more often residual pain and revision surgery after HAS, when compared to THA at short-term, with conversions rate of one fourth. However, THA in this patient group showed high infection rate of 5%. This information is relevant for counselling above-mentioned patients.

Reprint of: Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but Not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories.

METHODS

We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model.

RESULTS

285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30).

CONCLUSIONS

Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Low Rates of 5-Year Secondary Surgery and Postoperative Complications After Primary Hip Arthroscopy in More Than 30,000 Patients

PURPOSE

To evaluate 90-day complications, 5-year secondary surgery rates, and risk factors for secondary surgery following primary hip arthroscopy performed for femoroacetabular impingement and/or labral tears using a large national dataset.

METHODS

A retrospective analysis was conducted using the PearlDiver Mariner151 database. Patients with International Classification of Diseases, Tenth Revision, diagnosis codes for femoroacetabular impingement and/or labral tear undergoing primary hip arthroscopy with femoroplasty, acetabuloplasty, and/or labral repair between 2015 and 2021 were identified. Those with concomitant International Classification of Diseases, Tenth Revision, codes for infection, neoplasm, or fracture were excluded, as were patients with a history of previous hip arthroscopy or total hip arthroplasty, or age ≥70 years. Rates of complications within 90 days of surgery were assessed. Five-year rates of secondary surgery-revision hip arthroscopy or conversion to total hip arthroplasty-were determined by Kaplan-Meier analysis, and risk factors for secondary surgery were identified by multivariate logistic regression.

RESULTS

A total of 31,623 patients underwent primary hip arthroscopy from October 2015 to April 2021, with annual volumes ranging from 5,340 to 6,343 surgeries per year. Femoroplasty was the most frequent surgical procedure (performed in 81.1% of surgical encounters), followed by labral repair (72.6%) and acetabuloplasty (33.0%). Ninety-day postoperative complication rates were low, with 1.28% of patients experiencing any complication. The 5-year secondary surgery rate was 4.9% (N = 915 patients). Multivariate logistic regression identified age <20 years (odds ratio [OR] 1.50; P < .001), female sex (OR 1.33; P < .001), class I obesity (body mass index 30-34.9: OR 1.30; P = .04), and class II/III obesity (body mass index ≥35.0: OR 1.29; P = .02) as independent predictors of secondary surgery.

CONCLUSIONS

In this study of primary hip arthroscopy, 90-day adverse events were low at 1.28%, and the 5-year secondary surgery rate was 4.9%. Age younger than 20 years, female sex, and obesity were risk factors for secondary surgery, suggesting the need for increased surveillance in these patient groups.

LEVEL OF EVIDENCE

Level IV, case series.

Survivorship, Outcomes, and Risk Factors for Conversion to Total Hip Arthroplasty After Revision Hip Arthroscopic Surgery in Obese Patients: Results at a Minimum 5-Year Follow-up

Background

There is a paucity of literature reporting outcomes after revision hip arthroscopic surgery in obese patients.

Purpose

To report the minimum 5-year survivorship, patient-reported outcomes (PROs), clinical benefit, and risk factors for conversion to total hip arthroplasty (THA) in obese patients after revision hip arthroscopic surgery.

Study Design

Case series; Level of evidence, 4.

Methods

Data were prospectively collected and retrospectively reviewed for patients who underwent revision hip arthroscopic surgery by a single surgeon between April 2010 and August 2016. Inclusion criteria were a body mass index ≥30 and baseline and minimum 5-year postoperative values for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1 and hip dysplasia. Survivorship was defined as no conversion to THA. Clinical benefit was measured using the minimal clinically important difference (MCID). Survivors and nonsurvivors underwent further bivariate and regression analyses to determine the predictors of conversion to THA.

Results

Included were 24 hips in 24 patients. The mean patient age was 39.3 ± 12.7 years, and the mean follow-up was 83.9 ± 26.5 months. The survivorship rate was 75.0%, and patients demonstrated a significant improvement in all PROs (P < .01). At 5-year follow-up, the MCID for the mHHS, NAHS, HOS-SSS, and VAS was achieved by 70.6%, 94.1%, 92.9%, and 64.7%, respectively, of the patients. Older age, higher grade ligamentum teres tears, and acetabuloplasty were significant on bivariate analysis for conversion to THA, and increased age was identified as a significant variable for conversion to THA on regression analysis (odds ratio, 1.297 [95% CI, 1.045-1.609]; P = .018), with a 29.7% greater risk for every additional year of age at the time of revision.

Conclusion

In this study, 25.0% of obese patients who underwent revision hip arthroscopic surgery required conversion to THA. The study patients who did not need conversion to THA had a significant improvement in all PROs, with >90% achieving MCID for one or more outcome measures. Older age was identified as a significant predictor of conversion to THA.

Class I Obesity Delays Achievement of Patient-Acceptable Symptom State but not Minimum Clinically Important Difference or Substantial Clinical Benefit After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

The aim of our study was to identify differences in the time taken to achieve the minimum clinically important difference (MCID), substantial clinical benefit (SCB), and patient-acceptable symptom state (PASS) following primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) among patients of different body mass index (BMI) categories.

METHODS

We conducted a retrospective comparative study of hip arthroscopy patients with minimum 2-year follow-up. BMI categories were defined as normal (18.5 ≤ BMI < 25.0), overweight (25.0 ≤ BMI <30.0), or class I obese (30.0≤BMI<35.0). All subjects completed the modified Harris Hip Score (mHHS) prior to surgery and at 6 months, 1 year, and 2 years postoperative. MCID and SCB cutoffs were defined as pre-to-postoperative increases in mHHS by ≥8.2 and ≥19.8, respectively. PASS cutoff was set at postoperative mHHS ≥74. Time to achievement of each milestone was compared using the interval-censored EMICM algorithm. The effect of BMI was adjusted for age and sex using an interval-censored proportional hazards model.

RESULTS

285 patients were included in the analysis: 150 (52.6%) normal BMI, 99 (34.7%) overweight, and 36 (12.6%) obese. Obese patients had lower mHHS at baseline (P = .006) and at 2-year follow-up (P = .008). There were no significant intergroup differences in time to achievement for MCID (P = .92) or SCB (P = .69), but obese patients had longer time to PASS than normal BMI patients (P = .047). Multivariable analysis found obesity to be predictive of longer time to PASS (HR = .55; P = .007) but not MCID (HR = 0.91; P = .68) or SCB (HR = 1.06; P = .30).

CONCLUSIONS

Class I obesity is associated with delays in achieving a literature-defined PASS threshold after primary hip arthroscopy for FAIS. However, future research should consider incorporating PASS anchor questions to determine whether obesity truly carries a risk of delayed achievement of a satisfactory state of health as it pertains to the hip.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Return to sport after arthroscopic surgery for femoroacetabular impingement

BACKGROUND

Femoroacetabular impingement (FAI) is common among the active and young population. The present study analysed the rate of return to sport, related influencing factors, and the sport activity level according to the Hip Outcome Score - Sport-Specific Subscale (HOS-SSS).

METHODS

The literature search was performed in December 2020. All clinical trials investigating HOS-SSS and/or return to sport after arthroscopic treatment for FAI were considered for inclusion. The outcomes of interest were to analyse the rate of return to sport and the sport activity level according to the HOS-SSS in patients who underwent arthroscopic osteoplasty for FAI.

RESULTS

Data from 41 studies (4063 procedures) were retrieved. A total of 88.75% (581 of 655) of patients returned to sports within a mean of 37.4 ± 16.5 months. The HOS-SSS score improved from 45.0 ± 10.6 to 73.1 ± 9.5 (P < 0.0001) at last follow-up. The following baseline characteristics evidenced positive association with post-operative activity level: lighter weight (P = 0.01), younger age (P = 0.001), Tönnis angle grade I (P = 0.009), greater HHS (P = 0.01), NAHS (P < 0.0001) and HOS-ADL (P = 0.01).

CONCLUSION

Arthroscopic treatment for FAI resulted in excellent results in terms of return to sport. Moreover, lighter weight and younger age, greater HHS, NAHS, HOS-ADL at baseline were positively associated with post-operative sport activity level.

LEVEL OF EVIDENCE

IV, systematic review.

Differential Impact of Body Mass Index in Hip Arthroscopy: Obesity Does Not Impact Outcomes

Background: Hip arthroscopy is commonly used for the treatment of hip pathologies. As population obesity rates continue to increase, elucidating the impact of body mass index (BMI) on hip arthroscopy outcomes is essential. This investigation was conducted to quantify the effects of BMI on hip arthroscopy outcomes. Methods: We conducted a retrospective medical records review of 459 patients undergoing hip arthroscopy at a single center from 2008 to 2016. The Harris Hip Score (HHS) and 2 component scores of the 12-Item Short Form Survey-the physical component score (PCS-12) and the mental component score (MCS-12)-were used to measure outcomes. Patients were stratified into 4 cohorts based on their BMI: underweight (BMI <18.5 kg/m²), normal weight (BMI 18.5 to 24.9 kg/m²), overweight (BMI 25.0 to 29.9 kg/m²), and obese (BMI ≥30.0 kg/m²). Results: At 1 and 2 years postoperatively, all cohorts experienced statistically significant improvements in the HHS and PCS-12. At 3 years postoperatively, statistically significant improvements were seen in the HHS for all cohorts; in the PCS-12 for the normal weight, overweight, and obese cohorts; and in the MCS-12 for the normal weight cohort. Intercohort differences were not statistically significant at 1, 2, or 3 years postoperatively. Conclusion: In our population, BMI did not have statistically significant effects on patient outcome scores following hip arthroscopy. All patient cohorts showed postoperative improvements, and differences between BMI cohorts were not statistically significant at any postoperative time point.

Equality in Hip Arthroscopy Outcomes Can Be Achieved Regardless of Patient Socioeconomic Status

BACKGROUND

Access to quality health care and treatment outcomes can be affected by patients' socioeconomic status (SES).

PURPOSE

To evaluate the effect of patient SES on patient-reported outcome measures (PROMs) after arthroscopic hip surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Demographic, radiographic, and intraoperative data were prospectively collected and retrospectively reviewed on all patients who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear between February 2008 and September 2017 at one institution. Patients were divided into 4 cohorts based on the Social Deprivation Index (SDI) of their zip code. SDI is a composite measure that quantifies the level of disadvantage in certain geographical areas. Patients had a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), International Hip Outcome Tool-12, and visual analog scale (VAS) for both pain and satisfaction. Rates of achieving the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for the mHHS, NAHS, and VAS pain score. Rates of secondary surgery were also recorded.

RESULTS

A total of 680 hips (616 patients) were included. The mean follow-up time for the entire cohort was 30.25 months. Division of the cohort into quartiles based on the SDI national averages yielded 254 hips (37.4%) in group 1, 184 (27.1%) in group 2, 148 (21.8%) in group 3, and 94 (13.8%) in group 4. Group 1 contained the most affluent patients. There were significantly more men in group 4 than in group 2, and the mean body mass index was greater in group 4 than in groups 1 and 2. There were no differences in preoperative radiographic measurements, intraoperative findings, or rates of concomitant procedures performed. All preoperative and postoperative PROMs were similar between the groups, as well as in the rates of achieving the MCID or PASS. No differences in the rate of secondary surgeries were reported.

CONCLUSION

Regardless of SES, patients were able to achieve significant improvements in several PROMs after hip arthroscopy for FAIS and labral tear at the minimum 2-year follow-up. Additionally, patients from all SES groups achieved clinically meaningful improvement at similar rates.

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.

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

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

Parameters affecting baseline hip function in patients with cam-derived femoroacetabular impingement syndrome: data analysis from the German Cartilage Registry

BACKGROUND

Using the database of the German Cartilage Registry (KnorpelRegister DGOU), this study aims to present patient- and joint-related baseline data in a large cohort of patients with cam-derived femoroacetabular impingement syndrome (FAI) and to detect symptom-determining factors.

MATERIALS AND METHODS

Requiring cam morphology as the primary pathology, 362 patients were found to be eligible for inclusion in the study. The assessment of preoperative baseline data was performed using the patient-reported outcome measure-International Hip Outcome Tool (iHOT-33). Descriptive statistics were performed to present baseline data. Univariate and multiple regression with post hoc testing were used to identify patient- and joint-related factors that might affect the preoperative iHOT-33 and its subscores, respectively.

RESULTS

The study collective's mean age was 36.71 ± 10.89 years, with 246 (68%) of them being male. The preoperative mean iHOT-33 total was 46.31 ± 20.33 with the subsection "sports and recreational activities" presenting the strongest decline (26.49 ± 20.68). The parameters "age," "sex," "body mass index" (BMI), and the confirmation of "previous surgery on the affected hip" were identified to statistically affect the preoperative iHOT-33. In fact, a significantly lower mean baseline score was found in patients aged > 40 years (p < 0.001), female sex (p < 0.001), BMI ≥ 25 kg/m² (p = 0.002) and in patients with previous surgery on the affected hip (p = 0.022). In contrast, the parameters defect grade and size, labral tears, and symptom duration delivered no significant results.

CONCLUSIONS

A distinct reduction in the baseline iHOT-33, with mean total scores being more than halved, was revealed. The parameters "age > 40 years," "female sex," "BMI ≥ 25," and confirmation of "previous surgery on the affected hip" were detected as significantly associated with decreased preoperative iHOT-33 scores. These results help to identify symptom-defining baseline characteristics of cam-derived FAI syndrome.

TRIAL REGISTRATION

The German Cartilage Registry is conducted in accordance with the Declaration of Helsinki and registered at germanctr.de (DRKS00005617). Registered 3 January 2014-retrospectively registered. The registration of data was approved by the local ethics committees of every participating institution. Primary approval was given by the ethics committee at the University of Freiburg (No. 105/13). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005617.

Hip arthroscopy and T-shaped capsular plication for the treatment of borderline dysplasia: a minimum 2-year follow-up

PURPOSE

The aim of the study was to evaluate the clinical outcomes of patients treated arthroscopically for symptomatic borderline dysplasia of the hip (BHD) with a T-shaped capsular plication, with a minimum follow-up of 24 months.

METHODS

Twenty-seven patients who had undergone hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All patients were clinically evaluated prior to surgery (T₀) and at two consecutive follow-ups (T₁: 12 ± 1.2 months; T₂: 52.0 ± 23.2 months) using the visual analogue scale (VAS) pain score, the Hip Outcome Score in activities of daily living (HOS-ADL) and sport-specific subscale (HOS-SSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-12 in its physical (PCS) and mental component scores (MCS). We also evaluated the presence of correlations and analysed the possible differences between subgroups.

RESULTS

We found a significant difference for HOS-ADL, HOS-SSS, VAS and WOMAC with the Friedman test for repeated measures through time points (p < 0.0001), but not for MCS. All clinical scores reported a significant improvement compared to the previous time point (p < 0.05), with the exception of HOS-SSS, for which p = 0.2570 between T₁ and T₂. The body mass index was positively correlated with preoperative VAS (R = 0.42857; p = 0.0257) and negatively correlated with PCS at T₀ (R = - 0.40999; p = 0.0337) and with PCS (R = - 0.40491; p = 0.0362), MCS (R = - 0.45939; p = 0.0159) and WOMAC (R = - 0.40573; p = 0.0216) at T₂. No complications were reported in our cohort.

CONCLUSIONS

The results of the current study confirm that patients with intra-articular hip pathology and concomitant BHD (LCEA 20°-25°) can benefit from arthroscopic treatment and that T-shaped capsular plication is one of the available options. Orthopaedic surgeons specialising in hip arthroscopy should consider arthroscopy for the treatment of symptomatic BHD for stabilising and strengthening the joint. Future studies should focus on finding out which type of patients can benefit most from this procedure.

LEVEL OF EVIDENCE IV

Prospective Case Series.

Successful return to sport in patients with symptomatic borderline dysplasia following hip arthroscopy and T-shaped capsular plication

PURPOSE

This study aims to evaluate the return to sport and correlations of patients with symptomatic borderline hip dysplasia (BHD) after hip arthroscopy and T-shaped capsular plication at a minimum follow-up of 24 months.

METHODS

Twenty-five patients who underwent hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All the patients were evaluated clinically prior to surgery (T₀) and at two consecutive follow-ups (T₁:15 ± 1.2 months and T₂: 53.9 ± 23.2 months) using the visual analogue scale (VAS) pain score, whereas sports activity was assessed by the Hip Outcome Score Sport Specific Subscale (HOS-SSS), the University of California, Los Angeles (UCLA) activity scale, the Tegner score and the physical component (PCS) of the Short Form-12 (SF-12). Furthermore, the presence of correlations and the possible differences between subgroups were evaluated and analysed.

RESULTS

A significant difference was found for HOS-SSS, VAS, Tegner, UCLA and PCS with the Friedman test for repeated measures through time points (p < 0.0001). Moreover, all the scores reported significant improvement compared to the previous time point (p < 0.0001) except the HOS-SSS between T₁ and T₂ (n.s.). Body Mass Index (BMI) was negatively correlated with HOS-SSS at T₀ (rho = - 0.526 p = 0.006) and T₁ (rho = - 0.425; p = 0.034), with Tegner at each follow-up (T₀: rho = - 0470 p = 0.017; T₁: rho = - 0.450; p = 0.024; T₂: rho = - 0.448; p = 0.024), with UCLA at T₁ (rho = - 0.396 p = 0.049), with pre-operative PCS (rho = - 0.413 p = 0.0401), and positively correlated with pre-operative VAS (rho = 0.436 p = 0.0291).

CONCLUSIONS

Hip arthroscopy and T-shaped capsular plication in young patients with symptomatic BHD demonstrates a significant increase in return to sport and physical activity and low risk of complications. T-shaped capsular plication procedure may be considered in young and active patients for whom non-operative treatment failed and who have a significant limitation in sports activity; in these patterns of patients, the ideal treatment should reliably allow fast recovery in combination with very low invasiveness which will prevent osteoarthritis. The results of this study provide more accurate information regarding return to sport in patients with BHD after hip arthroscopy and T-shaped capsular plication.

LEVEL OF EVIDENCE

Level IV.

Obesity is associated with less favorable outcomes following hip arthroscopic surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to systematically review the existing literature comparing the postoperative outcomes after following hip arthroscopy in obese and non-obese patients.

METHODS

Studies comparing the outcomes following hip arthroscopy of obese and non-obese patients were systematically identified via a computer-assisted literature search of Pubmed (Medline), EMBASE, and Cochrane Library using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Studies comparing the outcome of hip arthroscopy in different body mass index (BMI) groups were included. Data including patient-reported outcome measures (PROMs), revision arthroscopy rate, conversion rate to total hip arthroplasty (THA), and complications were collected. The methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess the quality of each study quality. The effect of heterogeneity was quantified by calculating the I² value.

RESULTS

A total of eight studies were finally included in the qualitative analysis, and three studies of high quality involving 373 hips were included in the quantitative assessment. All the studies defined obesity as a BMI of  ≥ 30 kg/m². The modified Harris Hip Score and the Non-Arthritic Hip Score were 5.1 (95% CI 1.1-9.1) and 9.0 (95% CI 5.0-13.1) points lower, respectively, in the obese group than in the non-obese group. The pooled odds ratios were 1.2 (95% CI 0.5-2.7) for revision arthroscopy, 2.4 (95% CI 1.3-4.6) for conversion to THA, and 3.2 (95% CI 1.2-8.6 for complications in favor of the non-obese group. The heterogeneity was low in all outcome assessments (I² 0-18%).

CONCLUSION

Obese patients had significantly lower PROMs than non-obese patients following hip arthroscopic surgery, and the THA conversion and complication rates were 2.4 times and 3.2 times higher, respectively. Understanding the effect of obesity on hip arthroscopy will allow appropriate surgical indications for surgery to be further refined and help obese patients to understand their individual risk profile.

LEVEL OF EVIDENCE

Systematic review of Level III-IV studies, Level IV.

The Influence of Body Mass Index on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Five-Year Results in 140 Patients

BACKGROUND

Significant short-term improvements in function and pain after arthroscopic management of femoroacetabular impingement syndrome (FAIS) have been demonstrated regardless of mass index (BMI). No studies have reported the influence of obesity on mid- to long-term outcomes.

PURPOSE

To evaluate the effect of BMI class on 5-year patient outcomes after arthroscopic treatment of FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of a prospective database was performed to identify patients who underwent arthroscopic treatment for FAIS. A matched-pair analysis for age and sex was performed in a 1:1:2:3 fashion for morbidly obese (BMI ≥35), obese (BMI = 30-34.9), overweight (BMI = 25-29.9), and normal weight (BMI = 18.5-24.9) patients, respectively. Patient characteristics, imaging, Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Subscale (HOS-SS) scores, modified Harris Hip Score (mHHS), and pain scores were recorded preoperatively, with the same outcome scores recorded at 5 years postoperatively, along with satisfaction scores. Standardized modern hip arthroscopy, with labral repair, acetabuloplasty, femoroplasty, and capsular plication followed by formalized rehabilitation, was performed for all patients. Absolute outcomes along with change in outcomes were assessed between BMI groups. A between-group analysis was also conducted evaluating achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for any outcome score. A multivariable analysis was additionally included to evaluate outcomes adjusting for known confounding variables.

RESULTS

A total of 140 patients with mean follow-up of 62.1 ± 6.5 months were identified: 20 morbidly obese, 20 obese, 40 overweight, and 60 normal weight. There were significant improvements for HOS-ADL, HOS-SS, and mHHS scores in the normal (all P < .0001) and overweight groups (all P < .0001), mHHS in the obese group (P = .0275), and no significant improvement in functional scores in the morbidly obese group (P > .05). Compared with normal controls, multivariable analysis, adjusting for confounders, showed similar improvement in HOS-ADL for patients in the overweight and obese groups, HOS-SS for patients in the overweight group, and mHHS for patients in the overweight and obese groups (all P > .05). All groups showed significant improvement in pain scores (all P < .01) that were not significantly different between groups in multivariable analysis (all P > .05). Obese BMI was associated with a 54.9-point decrease in 5-year HOS-SS, and morbidly obese BMI was associated with a 27.3, 35.0, and 23.7-point decrease in 5-year HOS-ADL, HOS-SS, and mHHS, respectively (all P < .05). Regarding surgical benefit in comparison with normal weight patients, patients in the overweight and obese groups were as likely to achieve MCID (reciprocal odds ratio [ROR]: 1.5 and 1.2, respectively, both P > .05), but patients in the morbidly obese group were not. All groups were significantly less likely than the normal weight group to achieve PASS (ROR: overweight 5.2, obese 14.1, morbidly obese 13.0; all P < .05) and SCB (ROR: overweight 3.9, obese 7.8, morbidly obese 20.3; all P < .05).

CONCLUSION

There were significant improvements in at least 1 outcome score across all BMI groups with arthroscopic treatment of FAIS. While the normal weight patients demonstrated universal improvement in all patient-reported outcomes and significantly greater likelihood of achieving PASS and SCB, the higher BMI groups still demonstrated significant improvement in function and pain, except for the morbidly obese group. Patients with morbid obesity demonstrated long-term pain improvement, although they did not experience functional improvement.

The influence of pain catastrophizing and central sensitization on the reported pain after hip arthroscopy

PURPOSE

This study was conducted to investigate whether the pain catastrophizing scale (PCS) and the central sensitization inventory (CSI) are predictive factors for the reported pain after hip arthroscopy.

METHODS

A total of 37 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome and labral tears were prospectively enrolled. All patients completed the PCS and CSI before hip arthroscopy. Postoperative pain was measured with the numeric rating scale (NRS) weekly the first 12 weeks after surgery by electronic diary.

RESULTS

At baseline, univariate analyses showed that both the CSI and PCS were significantly associated with the NRS outcome (p < 0.01). During 12 weeks follow-up, a significant decrease on the NRS was observed (p < 0.01). Univariate analyses showed that both the CSI and PCS were significantly associated with the NRS during follow-up. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.07 (95% CI 0.03-0.11, p < 0.01).

CONCLUSION

Results indicate that both the PCS and CSI are associated with the reported postoperative pain after hip arthroscopy. The PCS and CSI may be useful in daily practice to identify patients that possibly benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery.

LEVEL OF EVIDENCE

IV.

Lumbosacral Transitional Vertebrae Predict Inferior Patient-Reported Outcomes After Hip Arthroscopy

BACKGROUND

While the association between spinal disease and hip arthroplasty outcomes has been well studied, there is less known about the effect of spinal pathology in hip arthroscopy (HA) outcomes. Lumbosacral transitional vertebrae (LSTV) are anatomic variations where caudal vertebrae articulate or fuse with the sacrum or ilium.

HYPOTHESIS

LSTV can lead to inferior outcomes after HA for treatment of femoroacetabular impingement.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We retrospectively reviewed the prospectively collected Hip Arthroscopy Database at our institution for patients with LSTV who underwent HA between 2010 and 2017. A total of 62 patients with LSTV were identified and then matched to controls. Patient-reported outcome measures (PROMs) were collected, including the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports, and the 33-item International Hip Outcome Tool. They were collected at 4 time points: preoperatively and 5 to 11 months, 12 to 23 months, and 24 to 35 months postoperatively. Longitudinal analysis of the PROMs was done using generalized estimating equation modeling. Additionally, alpha angles were measured from preoperative radiographic data.

RESULTS

Preoperatively, there was no significant difference between patients with and without LSTV on 3 of the 4 PROMs; however, patients with LSTV did have significantly lower preoperative scores than controls for the Hip Outcome Score-Activities of Daily Living (P = .029). Patients with LSTV reported significantly lower scores on all 4 PROMs at each postoperative time point. Radiographic data showed no significant difference in alpha angles across cohorts. When LSTV were compared by Castellvi type, types 3 and 4 tended to have lower scores than types 1 and 2; however, these comparisons were not significant.

CONCLUSION

The data support our hypothesis that HA has less benefit in patients with LSTV as compared with patients without LSTV. In patients with LSTV, careful evaluation of the anomaly is recommended to help guide surgical counseling and manage expectations.

Cystoscopy as a tool for hip arthroscopy for treating morbidly obese patients: a case report of treating a Sumo wrestler

Sports medicine surgeons sometimes encounter morbidly obese athletes with femoroacetabular impingement, such as Sumo wrestlers. In such cases, traditional arthroscopic equipment will not reach the joint. This case report describes the use of a cystoscope to perform arthroscopy to treat borderline developmental dysplasia of the hip combined with cam impingement in a morbidly obese athlete. The cystoscope enables hip arthroscopy to be performed when traditional instruments are not of sufficient length to access the hip and/or an extra-long arthroscope is not available. The use of the cystoscope provides a practical, feasible and minimally invasive option to treat non-arthritic intraarticular hip pathology in the morbidly obese or extremely muscular athletes.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effect of Patient Body Mass Index, Recommendation for Weight Modification, and Nonmodifiable Factors on Patient Satisfaction

INTRODUCTION

Patient satisfaction serves an increasingly important role in health care. Multiple nonmodifiable patient factors have been found to influence patient satisfaction. To the best of our knowledge, however, no study has investigated the influence of body mass index (BMI) on satisfaction scores. The objective of this study was to evaluate whether BMI and provider recommendation for patient weight modification were associated with patient satisfaction.

METHODS

We reviewed Press Ganey patient satisfaction survey scores from 3,044 clinical encounters in an academic orthopaedic center between November 2010 and May 2017. Multiple patient factors, BMI, and recommendation for weight loss, or requirement of weight loss, before surgery were recorded. Patient satisfaction was operationalized as a binary outcome of completely satisfied or not completely satisfied, and multiple logistic regression was used to estimate the odds of being completely satisfied from the subset of potential predictors.

RESULTS

White patients (odds ratio [OR] = 1.340, 95% confidence interval [CI]: 1.113 to 1.584, P = 0.0007) and Medicare-insured patients (OR = 1.260, 95% CI: 1.044 to 1.521, P = 0.0164) were more likely to be completely satisfied, whereas patients being seen by a provider for the first time were less likely to be completely satisfied (OR = 0.728, 95% CI: 0.626 to 0.847, P < 0.0001). BMI, recommendation for weight loss, and requirement of weight modification before surgery were not found to be associated with patient satisfaction.

DISCUSSION

Neither patient BMI nor provider recommendation for weight loss, or as a requirement for surgery, was associated with patient satisfaction. Race, insurance status, and previous visits with the care provider were identified as nonmodifiable patient factors that influence patient satisfaction.

LEVEL OF EVIDENCE

Level III.

Best Practice Guidelines for Hip Arthroscopy in Femoroacetabular Impingement: Results of a Delphi Process

BACKGROUND

Treatment algorithms for the arthroscopic management of femoroacetabular impingement (FAI) syndrome remain controversial because of a paucity of evidence-based guidance. Consequently, notable variability in clinical practice exists between different practitioners, necessitating expert consensus. The purpose of this study is to establish best practice guidelines (BPG) using formal techniques of consensus building among a group of experienced hip arthroscopists driven by the results of a systematic review and meta-analysis. The scope of these guidelines includes preoperative recommendations, intraoperative practices, and postoperative protocols.

METHODS

The validated Delphi process and the nominal group technique (NGT), used by the Centers for Disease Control and Prevention and the peer-reviewed orthopaedic literature, were used to formally derive consensus among 15 surgeons in North America. Participants were surveyed for current practices, presented with the results of a meta-analysis and systematic literature review, and asked to vote for or against the inclusion of nonleading, impartially phrased items during three iterative rounds while preserving the anonymity of participants' opinions. Agreement greater than 80% was considered consensus, and items near consensus (70% to 80% agreement) were further queried using the NGT in a moderated group session at the American Orthopaedic Society for Sports Medicine annual meeting.

RESULTS

Participants had a mean of 12.3 years of practice (range: 1 to 29 years) and performed an annual mean of 249 (range 100 to 500+) hip arthroscopies, with a combined total of approximately 52,580 procedures. Consensus was reached for the creation of BPG consisting of 27 preoperative recommendations, 15 intraoperative practices, and 10 postoperative protocols. The final checklist was supported by 100% of participants.

CONCLUSION

We developed the first national consensus-based BPG for the surgical and nonsurgical management of FAI. The resulting consensus items can serve as a tool to reduce the variability in preoperative, intraoperative, and postoperative practices and guide further research for the arthroscopic management of FAI.

Radiographic and Demographic Factors Can Predict the Need for Primary Labral Reconstruction in Hip Arthroscopic Surgery: A Predictive Model Using 1398 Hips

BACKGROUND

Labral tears are the most common findings in patients with symptomatic femoroacetabular impingement (FAI). The restoration of labral function is critical, and labral reconstruction has been proposed as an alternative for irreparable tears.

PURPOSE

To compare preoperative radiographic measurements and demographics of patients who underwent primary arthroscopic labral reconstruction versus primary labral repair and to identify factors that are predictive of the need for reconstruction.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Patients who underwent their index hip arthroscopic procedure between October 2010 and November 2018 and underwent either labral reconstruction or repair were included in the study. A total of 18 variables (14 radiographic and 4 demographic) were assessed in a bivariate comparison and analyzed in a multivariate logistic model.

RESULTS

A total of 251 primary reconstruction and 1147 primary repair procedures were included. The logistic model selected age, body mass index (BMI), Tönnis grade, lateral center-edge angle (LCEA), and alpha angle. The odds of reconstruction were 2.52 times higher in patients with Tönnis grade 1 than 0 (odds ratio [OR], 2.52 [95% CI, 1.82-3.49]). Each additional degree in the LCEA was associated with a 6% increase in the odds of reconstruction (OR, 1.06 [95% CI, 1.04-1.09]) and 4% for each additional degree in the alpha angle (OR, 1.04 [95% CI, 1.03-1.05]). Higher age (per log 10 unit) and BMI also increased the likelihood of reconstruction (OR, 11.29 [95% CI, 4.23-30.10] and OR, 1.03 [95% CI, 1.00-1.06], respectively).

CONCLUSION

In a multivariate analysis, factors identified as preoperative predictors for primary arthroscopic labral reconstruction in the setting of FAI and labral tears were Tönnis grade, LCEA, age, and BMI. These predictive factors may be useful for the clinician in determining the preoperative likelihood of primary labral reconstruction.

Forget the Greater Trochanter! Hip Joint Access With the 12 O'clock Portal in Hip Arthroscopy

Most surgeons rely on the greater trochanter as the reference point to establish the anterolateral portal. Nevertheless, we believe that the anterosuperior iliac spine is a more reliable landmark. Unlike the greater trochanter, it is unaffected by leg rotation and is more easily identified by palpation. Abiding by the central tenet of medicine to "do no harm," the technique described herein presents in detail the concept of the 12 o'clock portal placement, a hip joint access method based on identifying specific anatomic points under fluoroscopy and by palpation. To accomplish this goal, this Technical Note presents a step-by-step approach, including tips and pearls for patient positioning and fluoroscopic guidance. We believe this method ensures a reproducible and safe way to start hip arthroscopy in the supine position.

Minimum Five-Year Outcomes of Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Labral Tears in Patients with Obesity: A Match-Controlled Study

BACKGROUND

Obesity is a negative prognostic factor for various surgical procedures. The purpose of this study was to compare patients with obesity who underwent hip arthroscopy for femoroacetabular impingement and labral tears with a match-controlled group of normal-weight patients.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent arthroscopy between February 2008 and December 2011. Inclusion criteria were treatment for femoroacetabular impingement and labral tears and completed preoperative patient-reported outcomes and visual analog scale (VAS) for pain. Exclusion criteria were previous ipsilateral hip conditions or preoperative Tönnis grade of ≥2. Patients with obesity (body mass index [BMI] of ≥30 kg/m) were matched and were compared with normal-weight patients (BMI of 18.5 to 24.99 kg/m) using a 1:1 ratio by age at the time of the surgical procedure within 5 years, sex, acetabular Outerbridge grade (0 or 1 compared with 2, 3, or 4), and capsular treatment.

RESULTS

Of the 96 obesity cases with follow-up, 74 were pair-matched to control cases. The mean BMI was 34.3 kg/m for the obesity group and 22.7 kg/m for the control group (p < 0.0001). The mean follow-up time was 71.6 months for the obesity group and 71.3 months for the control group (p = 0.41). All mean preoperative patient-reported outcomes and VAS scores for patients without conversion to total hip arthroplasty were significantly worse in the obesity group: modified Harris hip score (p = 0.0001), Non-Arthritic Hip Score (p = 0.0001), Hip Outcome Score Sports-Specific Scale (HOS-SSS) (p = 0.015), and VAS (p = 0.01). No significant differences were observed with regard to demographic characteristics, intraoperative findings, procedures, follow-up scores, magnitudes of improvement, or secondary arthroscopy rates (p > 0.05). Both groups demonstrated significant improvements in mean outcome scores at ≥5 years (p < 0.0001). In both groups, no significant differences were detected in mean outcome scores between 2 years and ≥5 years (p > 0.05). The conversion rate to total hip arthroplasty was 29.7% for the obesity group and 14.9% for the control group (relative risk, 2.0 [95% confidence interval, 1.1 to 3.8]; p = 0.04).

CONCLUSIONS

Hip arthroscopy for the treatment of femoroacetabular impingement and labral tears in patients with obesity yielded significant improvements at ≥5 years; these results were similar to a matched group of normal-weight patients. However, patients with obesity demonstrated a twofold increased risk of conversion to total hip arthroplasty.

LEVEL OF EVIDENCE

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

Are Results of Arthroscopic Labral Repair Durable in Dysplasia at Midterm Follow-up? A 2-Center Matched Cohort Analysis

BACKGROUND

Studies assessing dysplasia's effect on hip arthroscopy are often limited to the short term and unable to account for demographic factors that may vary between dysplastic and nondysplastic populations.

PURPOSE

To determine the midterm failure rate and patient-reported outcomes of arthroscopic labral repair in the setting of dysplasia and make subsequent failure and outcome comparisons with a rigorously matched nondysplastic control group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Primary arthroscopic labral repair cases at 2 centers from 2008 to 2011 were reviewed. Patients with lateral center edge angle (LCEA) <25° were matched to nondysplastic controls by age, sex, laterality, body mass index (BMI), Tönnis grade, and capsular repair per a 1:2 matching algorithm. Groups were compared with a visual analog scale (VAS) for pain, modified Harris Hip Score (mHHS), and Hip Outcome Score-Sports Specific Subscale (HOS-SSS) to determine predictors of outcome and failure.

RESULTS

Forty-eight patients with dysplasia (mean LCEA, 21.6°; range, 13.0°-24.9°; n = 25 with capsular repair) were matched to 96 controls (mean LCEA, 32.1°; range, 25°-52°; n = 50 with capsular repair) and followed for a mean of 5.7 years (range, 5.0-7.7 years). Patients achieved mean VAS improvements of 3.3 points, mHHS of 19.5, and HOS-SSS of 29.0 points ( P < .01) with no significant differences between the dysplasia and control populations ( P > .05). Five-year failure-free survival was 83.3% for patients with dysplasia and 78.1% for controls ( P = .53). No survival or outcomes difference was observed between patients with dysplasia who did or did not have capsular repair ( P ≥ .45) or when comparing LCEA <20° and LCEA 20° to 25° ( P ≥ .60). BMI ≤30 was associated with increased revision surgery risk ( P < .01). Age >35 years ( P < .05) and Tönnis grade 0 radiographs ( P < .01) predicted failure to reach minimal clinically important differences.

CONCLUSION

With careful selection and modern techniques, patients with dysplasia can benefit significantly and durably from arthroscopic labral repair. The dysplastic cohort had outcomes and failure rates similar to those of rigorously matched controls at midterm follow-up. Subanalyses comparing LCEA <20° and LCEA 20° to 25° are presented for completeness; however, this study was not designed to detect differences in dysplastic subpopulations. BMI ≤30 was associated with increased revision risk. Age >35 years and Tönnis grade 0 radiographs predicted failure to achieve minimal clinically important differences.

Progression to total hip arthroplasty following hip arthroscopy

BACKGROUND

Hip arthroscopy is a minimally invasive surgical technique increasingly being used to treat hip pathology. There is evidence that a proportion of patients require total hip arthroplasty in the years immediately following arthroscopy, suggesting that these patients have derived only a limited benefit from the procedure. Identification of risk factors for early progression to hip arthroplasty may enable refinement of hip arthroscopy indications and more informed decision making. The aim of this study is to identify the proportion of patients in a hip arthroscopy cohort who progress to total hip arthroplasty within 2 years of arthroscopy, and to analyse risk factors for this early progression.

METHODS

A retrospective cohort analysis was conducted on all patients who underwent hip arthroscopy at one tertiary institution from 2004 to 2013. Hospital data were linked to the Australian Orthopaedic Association National Joint Replacement Registry in 2016 to identify subsequent hip arthroplasty.

RESULTS

There were 989 arthroscopies performed on 947 patients; 447 were female (48.1%), the mean age was 41.1 years (SD: 14.23) and osteoarthritis was present at arthroscopy in 31.5%. Total hip arthroplasty occurred in 129 patients (13%) within 2 years. Multivariable logistic regression revealed osteoarthritis, age >50 years and previous arthroscopy were significant risk factors for arthroplasty within 2 years (adjusted odds ratios (confidence intervals): 4.6 (2.91-7.16), 3.8 (2.44-5.87), 2.5 (1.16-5.81)).

CONCLUSIONS

Osteoarthritis, older age and history of arthroscopy were independent risk factors for early progression to arthroplasty; these factors should be considered within clinical decision-making, and when discussing potential arthroscopy outcomes with patients.

Developing a risk prediction model for the functional outcome after hip arthroscopy

BACKGROUND

Hip arthroscopic treatment is not equally beneficial for every patient undergoing this procedure. Therefore, the purpose of this study was to develop a clinical prediction model for functional outcome after surgery based on preoperative factors.

METHODS

Prospective data was collected on a cohort of 205 patients having undergone hip arthroscopy between 2011 and 2015. Demographic and clinical variables and patient reported outcome (PRO) scores were collected, and considered as potential predictors. Successful outcome was defined as either a Hip Outcome Score (HOS)-ADL score of over 80% or improvement of 23%, defined by the minimal clinical important difference, 1 year after surgery. The prediction model was developed using backward logistic regression. Regression coefficients were converted into an easy to use prediction rule.

RESULTS

The analysis included 203 patients, of which 74% had a successful outcome. Female gender (OR: 0.37 (95% CI 0.17-0.83); p = 0.02), pincer impingement (OR: 0.47 (95% CI 0.21-1.09); p = 0.08), labral tear (OR: 0.46 (95% CI 0.20-1.06); p = 0.07), HOS-ADL score (IQR OR: 2.01 (95% CI 0.99-4.08); p = 0.05), WHOQOL physical (IQR OR: 0.43 (95% CI 0.22-0.87); p = 0.02) and WHOQOL psychological (IQR OR: 2.40 (95% CI 1.38-4.18); p = < 0.01) were factors in the final prediction model of successful functional outcome 1 year after hip arthroscopy. The model's discriminating accuracy turned out to be fair, as 71% (95% CI: 64-80%) of the patients were classified correctly.

CONCLUSIONS

The developed prediction model can predict the functional outcome of patients that are considered for a hip arthroscopic intervention, containing six easy accessible preoperative risk factors. The model can be further improved trough external validation and/or adding additional potential predictors.

Multicenter Analysis of Midterm Clinical Outcomes of Arthroscopic Labral Repair in the Hip: Minimum 5-Year Follow-up

BACKGROUND

The technique of hip arthroscopic surgery is advancing and becoming more commonly performed. However, most current reported results are limited to short-term follow-up, and therefore, the durability of the procedure is largely unknown.

PURPOSE

To perform a multicenter analysis of mid-term clinical outcomes of arthroscopic hip labral repair and determine the risk factors for patient outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data of primary hip arthroscopic labral repair performed at 4 high-volume centers between 2008 and 2011 were reviewed retrospectively. Patients were assessed preoperatively and postoperatively with the visual analog scale (VAS), modified Harris Hip Score (mHHS), and Hip Outcome Score-Sports-Specific Subscale (HOS-SSS) at a minimum of 5 years' follow-up. Factors including age, body mass index (BMI), Tönnis grade, and cartilage grade were analyzed in relation to outcome scores, and revision rates were determined. Failure was defined as subsequent ipsilateral hip surgery, including revision arthroscopic surgery and open hip surgery.

RESULTS

A total of 303 patients (101 male, 202 female) with a mean age of 32.0 years (range, 10.7-58.9 years) were followed for a mean of 5.7 years (range, 5.0-7.9 years). Patients achieved mean improvements in VAS of 3.5 points, mHHS of 20.1 points, and HOS-SSS of 29.3 points. Thirty-seven patients (12.2%) underwent revision arthroscopic surgery, and 12 (4.0%) underwent periacetabular osteotomy, resurfacing, or total hip arthroplasty during the study period. Patients with a BMI >30 kg/m² had a mean mHHS score 9.5 points lower and a mean HOS-SSS score 15.9 points lower than those with a BMI ≤30 kg/m² ( P < .01). Patients aged >35 years at surgery had a mean mHHS score 4.5 points lower and a HOS-SSS score 6.7 points lower than those aged ≤35 years ( P = .03). Patients with Tönnis grade 2 radiographs demonstrated a 12.5-point worse mHHS score ( P = .02) and a 23.0-point worse HOS-SSS score ( P < .01) when compared with patients with Tönnis grade 0.

CONCLUSION

Patients demonstrated significant improvements in VAS, mHHS, and HOS-SSS scores after arthroscopic labral repair. However, those with Tönnis grade 2 changes preoperatively, BMI >30 kg/m², and age >35 years at the time of surgery demonstrated significantly decreased mHHS and HOS-SSS scores at final follow-up.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case-control study.

The Influence of Body Mass Index on Outcomes After Hip Arthroscopic Surgery With Capsular Plication for the Treatment of Femoroacetabular Impingement

BACKGROUND

It remains unknown how variations in body mass index (BMI) influence outcomes after primary hip arthroscopic surgery with capsular plication for femoroacetabular impingement (FAI).

PURPOSE

To evaluate the effect that abnormal BMI (namely, overweight, obese, morbidly obese, and underweight) versus normal weight has on patient-reported clinical outcomes more than 2 years postoperatively from primary hip arthroscopic surgery with capsular plication by a single surgeon.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A clinical repository containing patients undergoing primary hip arthroscopic surgery for FAI between January 1, 2012, and January 1, 2014, with a minimum 2-year follow-up was queried. Outcome measures included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports, modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain; satisfaction, and Patient Acceptable Symptomatic State (PASS) for the HOS-ADL; scores were collected preoperatively and at 3 months, 1 year, and minimum 2 years postoperatively. Included patients were segregated by preoperative BMI into the following categories: underweight (<18.5 kg/m²), normal (18.5-24.9 kg/m²), overweight (25.0-29.9 kg/m²), obese (30.0-34.9 kg/m²), and morbidly obese (≥35.0 kg/m²). A multivariate logistic regression model controlling for patient demographics and disease severity was used to identify independent associations between BMI categories and outcomes. A Bonferroni adjustment lowered the threshold for significance to P < .01.

RESULTS

There were 409 hips in 381 patients appropriate for study inclusion: 7 underweight, 197 normal BMI, 130 overweight, 31 obese, and 16 morbidly obese. The mean age was 33.1 ± 12.1 years, with 232 (61%) female patients. At 2 years postoperatively, significant differences in the trend among HOS-ADL, HOS-Sports, and mHHS scores were evident, with normal BMI patients, followed by underweight patients, demonstrating greater scores than their overweight, obese, and morbidly obese counterparts. Obese patients demonstrated lower satisfaction scores than normal BMI patients. Overweight, obese, and morbidly obese patients had lower improvements in VAS pain scores compared with normal BMI patients. Increasing BMI (not subdivided into the 5 BMI categories) was associated with a higher infection risk (mean BMI for infections: 32.3 ± 9.8 kg/m² vs mean BMI for noninfections: 25.2 ± 4.8 kg/m²; P = .0035). However, with multivariate analysis, no significant differences in patient clinical outcomes between the BMI categories met the threshold for significance. Among obese patients (BMI ≥30.0 kg/m²), no specific risk factors were found to be significantly associated with decreases in the change in VAS, HOS-ADL, HOS-Sports, mHHS, satisfaction, or PASS for the HOS-ADL scores. However, because of the small cohort sizes at the extremes of the BMI categories, this analysis may have been underpowered to identify a significant difference in underweight or morbidly obese patients.

CONCLUSION

In the current cohort, there were multiple potential confounding variables, and while some clinical differences were observed initially (higher HOS-ADL, HOS-Sports, and mHHS scores for normal BMI patients than overweight and obese patients at 2 years postoperatively; lower satisfaction scores for obese patients than normal BMI patients; and lower improvement in VAS pain scores for overweight, obese, and morbidly obese patients when compared with normal BMI patients), after multivariate analysis, no associations were observed between BMI and clinical outcomes after hip arthroscopic surgery with capsular plication for FAI.

Outcomes of Hip Arthroscopic Surgery in Patients With Tönnis Grade 1 Osteoarthritis at a Minimum 5-Year Follow-up: A Matched-Pair Comparison With a Tönnis Grade 0 Control Group

BACKGROUND

Studies on midterm outcomes of the arthroscopic treatment of femoroacetabular impingement (FAI) and labral tears with mild osteoarthritis (OA) are limited.

PURPOSE

To evaluate outcomes of the arthroscopic treatment of FAI and labral tears in patients with mild preoperative OA (Tönnis grade 1) at a minimum 5-year follow-up, and to perform a matched-pair comparison to a control group with Tönnis grade 0.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected on patients who underwent hip arthroscopic surgery between February 2008 and April 2011. Inclusion criteria were arthroscopic treatment for FAI and labral tears and having preoperative patient-reported outcome (PRO) scores, including the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score-Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) scores for pain. Exclusion criteria were workers' compensation claims, preoperative Tönnis grade ≥2, and previous hip conditions (ipsilateral surgery, slipped capital femoral epiphysis, avascular necrosis, and dysplasia). Patients with minimum 5-year outcomes were eligible for matching on a 1:1 ratio (Tönnis grade 0 vs 1) based on age ±5 years, body mass index ±5 kg/m², sex, labral treatment, and capsular treatment.

RESULTS

Of 356 eligible hips, 292 hips had minimum 5-year outcomes (82%). Eighty-five hips with Tönnis grade 1 were evaluated. At 5-year follow-up, patients with Tönnis grade 1 had significant improvements in all PRO and VAS scores ( P < .0001). The overall satisfaction score was 8.2. The survivorship rate with respect to conversion to total hip arthroplasty for the Tönnis grade 1 group was 69.4% at 5 years, while in the Tönnis grade 0 group, it was 88.4% ( P = .0002). Sixty-two hips with Tönnis grade 0 were matched to 62 hips with Tönnis grade 1. Both groups demonstrated improvements in all PRO and VAS scores from preoperatively to postoperatively ( P < .0001). No significant differences existed between preoperative or postoperative scores or survivorship between the groups.

CONCLUSION

The arthroscopic treatment of FAI and labral tears in patients with Tönnis grade 1 had good results at 5-year follow-up. After controlling for other variables using a matched-pair comparison, patients with Tönnis grade 1 had similar, durable improvements to those with Tönnis grade 0. While strict surgical indications and appropriate expectations are recommended for patients with mild OA, Tönnis grade 1 alone should not be considered a contraindication to hip arthroscopic surgery.

Arthroplasty versus Internal Fixation for Displaced Intracapsular Femoral Neck Fracture in the Elderly: Systematic Review and Meta-analysis of Short- and Long-term Effectiveness

BACKGROUND

There is conflicting evidence as to whether the femoral head should be preserved or replaced in elderly patients with displaced intracapsular femoral neck fractures. In this article, we performed a systematic review and meta-analysis to compare the short- and long-term effectiveness of arthroplasty (AR) and internal fixation (IF).

METHODS

PubMed, Embase, and the Cochrane Library were searched systematically up to January 2016. All randomized controlled trials directly comparing the effectiveness of AR and IF for displaced intracapsular fracture were retrieved with no limitation on language or publication year.

RESULTS

In total, eight prospective randomized studies involving 2206 patients were included. The results of our study showed that patients in the AR group reported significantly lower complication (risk ratio: 0.56, 95% confidence interval [CI] = 0.38-0.80), re-operation (risk ratio: 0.17, 95% CI = 0.13-0.22), revision rates (risk ratio: 0.11, 95% CI: 0.08-0.16), and better function compared with their IF counterparts, and they were less likely to suffer postoperative pain. No statistically significant differences for the rates of mortality, infection, and/or deep vein thrombosis between AR and IF were found.

CONCLUSIONS

Based on our analysis, we recommend that AR should be used as the primary treatment for displaced intracapsular femoral neck fractures in the elderly. However, IF may be appropriate for those who are very frail.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.