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Martins EC, Gomes DA, Fernandes DA, de Brito Fontana H. Alpha Angle Values Predict the Severity of Hip Chondral Damage in Patients With Cam-Type Femoroacetabular Impingement Syndrome: A Systematic Review and Meta-analysis. Arthroscopy 2024:S0749-8063(24)00634-0. [PMID: 39303967 DOI: 10.1016/j.arthro.2024.08.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 08/19/2024] [Accepted: 08/20/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE To assess the role of alpha angle (AA) in predicting the severity of hip chondral damage in patients with cam-type femoroacetabular impingement (FAI) syndrome. METHODS Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols guidelines, a systematic review was performed to summarize and critically appraise studies analyzing the prognostic capability of AA values in predicting the severity of intraoperatively evaluated hip chondral damage in patients with cam-type FAI syndrome. The risk of bias was assessed through the Quality In Prognosis Studies tool. Meta-analyses based on groups and individual data from studies with a low risk of bias were conducted. We employed a cumulative link mixed model to analyze the relationship between AA and the ordinal outcome (chondral damage). The model was adjusted for sex, age, and the lateral center-edge angle (LCEA). Interactions between sex and AA were also investigated, and probabilities were calculated. RESULTS Twelve studies with 4,564 patients were included in a qualitative review (aged 30-39 years, 1,822 women [40%]). Studies with a low risk of bias (n = 4; 2,945 patients) indicated that AA values are significantly smaller (mean difference [95% confidence interval] of 10.5° [6.5°-15°]) in the low-grade chondral damage group (grades 0/I/II) compared with the high-grade chondral damage group (III/IV). The cumulative link mixed model with individual patient data from studies with low risk of bias (n = 3; 1,460 patients) indicated that for each 1° increase in AA, the odds of being in a greater category of chondral damage increased by a factor of 1.04 (odds ratio 1.04, P < .0001). Men were at significantly greater risk (odds ratio 2.11, P < .0001) than women, but no significant interaction between sex and AA was observed (P = .054). We estimate the average probability of having high-grade chondral damage to be greater than 33% when AA values surpass 71° for men and 90° for women, and greater than 50% when 89° for men and 108° for women. However, the heterogeneity observed across studies should be considered. CONCLUSIONS The AA is a significant predictor of hip chondral damage severity in patients with cam-type FAI syndrome, regardless of sex and independently of age and LCEA. In addition, men are at a greater risk of chondral damage than women, and this risk increases with aging but decreases with the magnitude of the LCEA. LEVEL OF EVIDENCE Level III, systematic review of Level II and III studies.
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Affiliation(s)
| | - Diogo A Gomes
- La Trobe Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, Australia
| | - Daniel Araujo Fernandes
- Department of Surgery, Polydoro Ernani de São Thiago University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Heiliane de Brito Fontana
- Department of Morphological Sciences, School of Biological Sciences, Federal University of Santa Catarina, Florianópolis, Brazil
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Niknam K, Freshman R, Flores SE, Lansdown DA, Wong SE, Zhang AL. Delayed hip arthroscopy for femoroacetabular impingement syndrome does not increase revision but does increase rates of chronic opiate use. J Orthop 2024; 53:49-54. [PMID: 38456177 PMCID: PMC10915368 DOI: 10.1016/j.jor.2024.02.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/24/2024] [Indexed: 03/09/2024] Open
Abstract
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.
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Affiliation(s)
- Kian Niknam
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Ryan Freshman
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Sergio E. Flores
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Drew A. Lansdown
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Stephanie E. Wong
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
| | - Alan L. Zhang
- Department of Orthopaedic Surgery, University of California - San Francisco, San Francisco, CA, USA
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Ramkumar PN, Olsen RJ, Shaikh HJF, Nawabi DH, Kelly BT. Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis. Am J Sports Med 2024; 52:1137-1143. [PMID: 38459690 DOI: 10.1177/03635465241232154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2024]
Abstract
BACKGROUND Little is known about the effect of modern hip arthroscopy on the natural history of femoroacetabular impingement syndrome (FAIS) with respect to joint preservation. PURPOSE To (1) characterize the natural history of FAIS and (2) understand the effect of modern hip arthroscopy by radiographically comparing the hips of patients who underwent only unilateral primary hip arthroscopy with a minimum follow-up of 10 years. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Between 2010 and 2012, 619 consecutive patients were reviewed from the practice of a single fellowship-trained hip arthroscopic surgeon. Inclusion criteria were FAIS, bilateral radiographic findings of femoroacetabular impingement, primary unilateral hip arthroscopy (labral repair, femoroplasty, or capsular closure), and minimum 10-year follow-up. The preoperative and minimum 10-year postoperative radiographs of patients were evaluated at each time point. Both operative and nonoperative hips were graded using the Tönnis classification or the presence of hip arthroplasty by 2 independent reviewers. Subgroup analyses were performed. RESULTS A total of 200 hips from 100 patients were evaluated at a mean follow-up of 12.0 years. Preoperatively, 98% and 99% of operative and nonoperative hips were evaluated as Tönnis grades 0 and 1, respectively; 5% of nonoperative hips had worse Tönnis grades than operative hips. The nonoperative hip advanced to a worse Tönnis grade in 48% (48/100) of cases compared with 28% (28/100) among operative hips. At follow-up, Tönnis grades between hips were equal in 70% (70/100) of the cases, the operative hip had a better grade 25% (25/100) of the time, and the nonoperative hip had a better grade 5% (5/100) of the time. Modern hip arthroscopy was associated with a relative risk reduction of 42% in osteoarthritis progression. Impingement with borderline dysplasia, age, preoperative Tönnis grade, and alpha angle >65° were key risk factors in the radiographic progression of osteoarthritis. CONCLUSION Although the majority of patients (70%) undergoing hip arthroscopy for FAIS did not experience differences between operative and nonoperative hips in terms of the radiographic progression of osteoarthritis, the natural history may be favorably altered for 25% of patients whose Tönnis grade was better after undergoing arthroscopic correction. Modern hip arthroscopy indications and techniques represent a valid joint-preservation procedure conferring a relative risk reduction of 42% in the progression of osteoarthritis. Arthroscopy for mixed patterns of impingement and instability were the fastest to degenerate.
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Affiliation(s)
- Prem N Ramkumar
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Long Beach Orthopaedic Institute, Long Beach, California, USA
| | - Reena J Olsen
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
| | | | - Danyal H Nawabi
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
| | - Bryan T Kelly
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
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Saito M, Kobayashi N, Honda H, Kamono E, Yukizawa Y, Choe H, Ike H, Kumagai K, Inaba Y. Physical Therapy May Not Be Successful for Patients With Cam-Type Femoroacetabular Impingement Syndrome and May Result in Insufficient Hip Range of Motion When Femoral Anteversion Is Less Than 16° and α-Angle Is Greater Than 65°. Arthroscopy 2024; 40:766-776.e1. [PMID: 37479152 DOI: 10.1016/j.arthro.2023.07.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 06/23/2023] [Accepted: 07/01/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To identify factors associated with insufficient range of motion (ROM) improvement after the posterior pelvic tilt change in cam-type femoroacetabular impingement syndrome. METHODS Preoperative computed tomography images from 71 consecutive patients with femoroacetabular impingement syndrome treated with arthroscopic cam resection were evaluated. Using a dynamic computer simulation program, 3-dimensional models with a 10° posterior pelvic tilt from the supine functional pelvic plane (baseline) were created by computed tomography models. Patients were divided into 2 groups: those who experienced >10° (effective group) and ≤10° (ineffective group) improvements in internal rotation at 90° flexion after a 10° posterior pelvic tilt. Demographic characteristics; preoperative range of internal rotation at 90° flexion; and radiographic parameters, including Tönnis grade, lateral center-edge angle, acetabular roof obliquity angle, central acetabular anteversion, cranial acetabular anteversion, femoral anteversion, and α angle, were compared in the 2 groups. Univariate and multivariable logistic regression analyses were performed to evaluate factors associated with insufficient ROM improvement following a 10° posterior pelvic tilt. RESULTS The 71 patients included 58 men and 13 women, of mean age 41.4 ± 14.6 years. Posterior pelvic tilt was effective in 13 hips and ineffective in 58. Univariate analysis showed that preoperative range of internal rotation at 90°flexion, femoral anteversion, and α angle differed significantly in the 2 groups. Multivariable analysis showed that femoral anteversion <16° (odds ratio 7.4; 95% confidence interval 1.6-35; P = .012) and α angle >65° (odds ratio 6.7; 95% confidence interval 1.2-37; P = .027) were significant factors associated with insufficient ROM improvement after posterior pelvic tilt. CONCLUSIONS Physical therapy may not be successful for patients with cam-type femoroacetabular impingement syndrome and may result in insufficient hip ROM when femoral anteversion is less than 16° and α-angle is greater than 65°. CLINICAL RELEVANCE Patients with a prominent cam-type deformity and lower anterior femoral anteversion are at high risk of clinical failure following improvement in pelvic mobility by conservative treatment alone and are likely to benefit from surgery for cam deformity.
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Affiliation(s)
- Masayoshi Saito
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan; Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan; Department of Orthopaedic Surgery, Hokusuikai Kinen Hospital, Mito, Ibaraki, Japan
| | - Naomi Kobayashi
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan.
| | - Hideki Honda
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Emi Kamono
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Yohei Yukizawa
- Department of Orthopaedic Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Hiroyuki Ike
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Ken Kumagai
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Yutaka Inaba
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
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Vaswani R. Editorial Commentary: Nonoperative Management Is the First Line of Treatment for Hip Femoroacetabular Impingement in Adolescents: Children Are Not Little Adults! Arthroscopy 2023; 39:2474-2476. [PMID: 37981389 DOI: 10.1016/j.arthro.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 05/13/2023] [Indexed: 11/21/2023]
Abstract
Adult patients undergoing hip arthroscopy who experience preoperative symptoms for a longer duration have worse outcomes postoperatively compared with those symptomatic for a shorter duration. Ongoing femoroacetabular impingement (FAI) may lead to worse damage that may not be fully reparable and could be used as evidence for early surgery. However, the same reasoning may not be applicable to adolescents for whom nonoperative treatment remains the first line of treatment for FAI. Many newly symptomatic FAI patients may actually have biomechanically treatable pathology of their hip, core, or spine, making their FAI symptomatic, and if these biomechanical factors can be corrected, the FAI may become asymptomatic. Patients with low pelvic incidence are "hip users" who compensate for their pelvic issue by increasing hip range of motion, making them more prone to symptomatic FAI and leading to degenerative changes from impingement. Only after failure to improve after a full course of physical therapy is established should adolescent patients and parents be counseled on hip arthroscopy as an appropriate treatment option.
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Ruzbarsky JJ, Comfort SM, Fukase N, Briggs KK, Vidal LB, Philippon MJ. Timing From Symptom Onset to Hip Arthroscopy Does Not Affect Patient-Reported Outcome Measures for the Treatment of Femoroacetabular Impingement in Adolescent Patients. Arthroscopy 2023; 39:2466-2473. [PMID: 37100216 DOI: 10.1016/j.arthro.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 03/30/2023] [Accepted: 03/31/2023] [Indexed: 04/28/2023]
Abstract
PURPOSE To evaluate symptom duration and its relationship to patient-reported outcomes (PROs) and survivorship after hip arthroscopy in adolescents. METHODS Patients ≤18 at time of primary hip arthroscopy for femoroacetabular impingement (FAI) between January 2011 and September 2018 were included. Exclusion criteria consisted of history of previous ipsilateral hip surgery, presence of osteoarthritis or dysplasia on preoperative radiographs, previous hip fracture, or history of slipped capital femoral epiphysis or Legg-Calve-Perthes disease. Minimum 2-year PROs (modified Harris Hip Score, Hip Outcome Score [HOS]-Activities of Daily Living, HOS-Sport Scale, Short Forms 12 [SF-12]), minimum clinically significant difference (MCID) and patient-acceptable symptom state (PASS) rates, and revision surgery rates were compared based on symptom duration. RESULTS Two-year minimal follow-up was obtained for 111 patients (134 hips) (80%), including 74 females and 37 males with a mean age of 16.4 ± 1.1 (range 13.0-18.0). The mean symptom duration was 17.2 ± 15.2 months (range 43 days to 6.0 years). Ten patients (11 hips), 6 females (7 hips) and 4 males, required revision surgery at an average of 2.3 ± 1.0 years (range 0.9-4.3 years). At a mean follow-up of 4.8 ± 2.2 years (range 2-10 years), there were statistically significant improvements in all PROs (P < .05 for all). Symptom duration showed no significant correlation to post-operative scores (correlation coefficient range -0.162 to -0.078, P > .05 for all). Symptom duration ≤12 months versus >12 months or as a continuous variable was not a predictor for requiring revision surgery or achieving MCID/PASS (95% confidence interval crosses 1 for all). CONCLUSIONS In an adolescent cohort of symptomatic FAI patients who underwent hip arthroscopy, there is no difference in PRO measures when analyzing symptom duration by arbitrary time intervals or as a continuous variable. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
- Joseph J Ruzbarsky
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | | | - Naomasa Fukase
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Karen K Briggs
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A
| | - Leslie B Vidal
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A
| | - Marc J Philippon
- Steadman Philippon Research Institute, Vail, Colorado, U.S.A; Steadman Clinic and United States Coalition for the Prevention of Illness and Injury in Sport, Vail, Colorado, U.S.A.
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Pasculli RM, Callahan EA, Wu J, Edralin N, Berrigan WA. Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome. Curr Rev Musculoskelet Med 2023; 16:501-513. [PMID: 37650998 PMCID: PMC10587039 DOI: 10.1007/s12178-023-09863-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/01/2023]
Abstract
PURPOSE To serve as a guide for non-operative physicians in the management of femoroacetabular impingement syndrome and provide an algorithm as to when to refer patients for potential surgical management. RECENT FINDINGS Supervised physical therapy programs that focus on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core-focused programs. There is promising evidence for the use of intra-articular hyaluronic acid and PRP as adjunct treatment options. Recent systematic reviews and meta-analyses have found that in young active patients, hip arthroscopy demonstrates improved short-term outcomes over physical therapy. The decision for the management of FAIS is complex and should be specific to each patient. Consideration of the patient's age, timing to return to sport, longevity of treatment, hip morphology, and degree of cartilage degeneration is required to make an informed decision in the treatment of these patients.
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Affiliation(s)
- Rosa M. Pasculli
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA USA
| | - Elizabeth A. Callahan
- Department of Physical Medicine and Rehabilitation, New York University, New York, NY USA
| | - James Wu
- University of California Berkeley, Berkeley, CA USA
| | - Niam Edralin
- University of California Berkeley, Berkeley, CA USA
| | - William A. Berrigan
- Department of Orthopaedics, University of California San Francisco, 1500 Owens Street, San Francisco, CA 94158 USA
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Kaplan DJ, Larson JH, Fenn TW, Allahabadi S, Malloy P, Nho SJ. Use and Effectiveness of Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement. Am J Sports Med 2023; 51:2141-2150. [PMID: 37259956 DOI: 10.1177/03635465231175151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Limited literature exists regarding how postoperative physical therapy (PT) may affect outcomes in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. Additionally, it is unknown how PT measures relate to traditional orthopaedic patient-reported outcomes (PROs). PURPOSE To evaluate how the duration of PT may correlate with outcomes in patients with FAIS using both the Lower Extremity Functional Scale (LEFS) and standard orthopaedic PRO measures. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients from a single institution who underwent primary hip arthroscopy for FAIS between 2013 and 2016 were identified. Patients with a minimum 2-year follow-up and fully documented PT notes were included and stratified into 3 cohorts based on timing of PT discharge: 0 to 3 months, 3 to 6 months, and 6 to 12 months. Predictive regression models were developed to analyze the rate of improvement (ROI) in LEFS score as it relates to (1) postoperative day (POD) and (2) postoperative PT session number. Two-year PROs were collected, correlated with LEFS scores, and compared among cohorts. RESULTS A total of 95 patients were included (mean ± SD age, 34.6 ± 11.7 years; range, 14-55 years). Mean LEFS scores increased significantly from the initial score at 6 weeks, 3 months, and the time of PT discharge (P < .01 for all). The predicted ROI in LEFS score was 3.39% per PT session for sessions 0 to 13, 1.43% for sessions 14 to 27, and 0.37% for sessions 28 to 40. Patients who underwent 3 to 6 months of PT had significantly better Hip Outcome Score (HOS) relative to the 0- to 3-month cohort and significantly better visual analog scale (VAS) scores for satisfaction relative to the 6- to 12-month cohort. The predicted ROI in LEFS score was 0.96% per day from POD 0 to 45, 0.22% from POD 46 to 139, and 0.03% after POD 139. Moderate correlations were seen between LEFS score at the time of discharge and all 2-year PROs as follows: HOS Activities of Daily Living subscale (r = 0.488), HOS Sports-Specific subscale (r = 0.500), modified Harris Hip Score (r = 0.465), 12-item International Hip Outcome Tool (r = 0.494), VAS pain score (r = -0.346), and VAS satisfaction score (r = 0.459). CONCLUSION Patients undergoing hip arthroscopy for FAIS derived substantial benefit from each PT visit during their first 13 PT sessions and then a smaller, yet still meaningful benefit from sessions 13 through 27. After session 40, or approximately 4.5 to 5 months, patients no longer benefited from additional PT sessions. Based on PRO scores, patients discharged from PT between 3 and 6 months had the best 2-year outcomes. LEFS score had moderate correlation with orthopaedic PRO scores.
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Affiliation(s)
- Daniel J Kaplan
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Jordan H Larson
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas W Fenn
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Sachin Allahabadi
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
| | - Philip Malloy
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
- Department of Physical Therapy, Arcadia University, Glenside, Pennsylvania, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois, USA
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Enseki KR, Bloom NJ, Harris-Hayes M, Cibulka MT, Disantis A, Di Stasi S, Malloy P, Clohisy JC, Martin RL. Hip Pain and Movement Dysfunction Associated With Nonarthritic Hip Joint Pain: A Revision. J Orthop Sports Phys Ther 2023; 53:CPG1-CPG70. [PMID: 37383013 DOI: 10.2519/jospt.2023.0302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
The Academy of Orthopaedic Physical Therapy (AOPT), formerly the Orthopaedic Section of the American Physical Therapy Association (APTA), has an ongoing effort to create evidence-based practice guidelines for orthopaedic physical therapy management of patients with musculoskeletal impairments described in the World Health Organization's International Classification of Functioning, Disability, and Health (ICF). This is an update to the 2014 Clinical Practice Guideline (CPG) for Hip Pain and Movement Dysfunction Associated with Nonarthritic Hip Joint Pain. The goals of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. This current CPG covers pathoanatomical features, clinical course, prognosis, diagnosis, examination, and physical therapy interventions in the management of nonarthritic hip joint pain. J Orthop Sports Phys Ther 2023;53(7):CPG1-CPG70. doi:10.2519/jospt.2023.0302.
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Lee SM, Kim JS, Moon NH, Woo SH, Park C, Shin WC. Recovery After Hip Arthroscopy in Patients With Combined Femoroacetabular Impingement and Labral Tears Compared With Isolated Pathology. Orthop J Sports Med 2023; 11:23259671231167908. [PMID: 37359977 PMCID: PMC10286186 DOI: 10.1177/23259671231167908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2023] [Accepted: 01/27/2023] [Indexed: 06/28/2023] Open
Abstract
Background Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology. Purpose To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT-12). Study Design Cohort study; Level of evidence, 3. Methods A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT-12 scores at 1.5, 3, 6, 12, 18, and >24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS). Results Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT-12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) (P < .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively (P < .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively. Conclusion The final iHOT-12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau.
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Affiliation(s)
- Sang-Min Lee
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Jung Shin Kim
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Nam Hoon Moon
- Department of Orthopaedic Surgery, Pusan National University Hospital, Busan, Republic of Korea
| | - Seung Hun Woo
- Department of Orthopaedic Surgery, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Chankue Park
- Department of Radiology, Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Won Chul Shin
- Department of Orthopaedic Surgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Republic of Korea
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Filan D, Mullins K, Carton P. Accelerated Bilateral Hip Arthroscopy (1 Week Apart): Outcomes Compared With Delayed Bilateral Procedure (4-12 Weeks) and Case-Control Matched Unilateral Arthroscopy. Am J Sports Med 2023; 51:1548-1559. [PMID: 37017256 DOI: 10.1177/03635465231162647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/06/2023]
Abstract
BACKGROUND Staged bilateral hip arthroscopy is an option for athletes who have symptomatic bilateral femoroacetabular impingement; however, the optimal timing of the second procedure is unknown. PURPOSE To evaluate minimum 2-year outcomes for patients undergoing accelerated bilateral arthroscopy against those undergoing (1) delayed bilateral and (2) unilateral arthroscopy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A retrospective review was performed of prospectively collected data from patients undergoing bilateral primary hip arthroscopy for femoroacetabular impingement between 2009 and 2022. Inclusion criteria entailed competitive athletes with concurrent bilateral symptoms at initial presentation. Exclusion criteria (either hip) were Tönnis grade >1, dysplasia (lateral center-edge angle <25°), Perthes disease, protrusio acetabuli, and avascular necrosis. Two groups were established based on the duration between procedures: within 7 days (accelerated group) and within 4 to 12 weeks (delayed group). Patients from the accelerated group were matched in a 1:2 ratio with patients undergoing unilateral surgery based on age ±2 years, sex, and athletic status. Minimum 2-year postoperative patient-reported outcomes (PROs) (including modified Harris Hip Score, University of California Los Angeles activity scale, 36-Item Short Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index), rates of achieving the minimal clinically important difference, rates of continuing to play main sport, and satisfaction were compared between groups. RESULTS A total of 131 athletes (262 hips) with bilateral femoroacetabular impingement were included: 91 in the accelerated group and 40 in the delayed group. Duration between surgeries was 0.99 ± 0.02 and 6.35 ± 2.18 weeks, respectively. All accelerated athletes were each successfully matched to 2 athletes with unilateral procedures (N = 182). All 3 groups demonstrated significant improvement from baseline across all PROs (P < .001 for all). Acquired change in PROs was similar and not significantly different between groups (P > .05). Satisfaction with relief from pain was achieved by 85.9% of patients in the accelerated group compared with 83.1% in the delayed group (P = .053) and 87.3% in the unilateral group (P = .933). The minimal clinically important difference for the modified Harris Hip Score was achieved by 84.9% of patients in the accelerated group compared with 91.5% in the delayed group (P = .212) and 87.6% in the unilateral group (P = .456). At 2 years postoperatively, the continue-to-play rate was 73.6% for the accelerated group compared with 77.1% for the delayed group (P = .577) and 73.0% for the unilateral group (P = .903). There were no increased complications associated with the accelerated group. CONCLUSION Accelerated bilateral hip arthroscopy 1 week apart was a safe and effective treatment option for athletes with bilateral symptoms. Improvement in PROs and continue-to-play rates were comparable with those after a delayed duration between procedures and with those case-control matched athletes undergoing unilateral arthroscopy.
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Affiliation(s)
- David Filan
- The Hip and Groin Clinic, UPMC Whitfield, Waterford, Ireland
| | | | - Patrick Carton
- The Hip and Groin Clinic, UPMC Whitfield, Waterford, Ireland
- UPMC Sports Medicine Clinic, Carriganore, Ireland
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12
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Impact of COVID-19 on Elective Orthopaedic Surgery Outcomes During the Peak of the Pandemic, an Uptick of Complications: An Analysis of the ACS-NSQIP. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202302000-00011. [PMID: 36802240 PMCID: PMC9945363 DOI: 10.5435/jaaosglobal-d-22-00276] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/23/2022] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Since the World Health Organization declared a pandemic in March 2020, COVID-19 has pressured the healthcare system. Elective orthopaedic procedures for American seniors were canceled, delayed, or altered because of lockdown restrictions and public health mandates. We sought to identify differences in the complication rates for elective orthopaedic surgeries before and atfter the pandemic onset. We hypothesized that complications increased in the elderly during the pandemic. METHODS We conducted a retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement Program database in patients older than 65 years undergoing elective orthopaedic procedures from 2019 (prepandemic) and April to December 2020 (during the pandemic). We recorded readmission rates, revision surgery, and 30-day postoperative complications. In addition, we compared the two groups and adjusted for baseline features with standard multivariate regression. RESULTS We included 146,430 elective orthopaedic procedures in patients older than 65 years (94,289 before the pandemic and 52,141 during). Patients during the pandemic had a 5.787 times greater chance of having delayed wait time to the operating room (P < 0.001), a 1.204 times greater likelihood of readmission (P < 0.001), and a 1.761 times increased chance of delayed hospital stay longer than 5 days (P < 0.001) when compared with prepandemic. In addition, during the pandemic, patients were 1.454 times more likely to experience any complication (P < 0.001) when compared with patients prepandemic undergoing orthopaedic procedures. Similarly, patients were also 1.439 times more likely to have wound complication (P < 0.001), 1.759 times more likely to have any pulmonary complication (P < 0.001), 1.511 times more likely to have any cardiac complication (P < 0.001), and 1.949 times more likely to have any renal complication (P < 0.001). CONCLUSION During the COVID-19 pandemic, elderly patients faced longer wait times within the hospital and increased odds of complications after elective orthopaedic procedures than similar patients before the pandemic.
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Kim DNW, Lee MS, Mahatme RJ, Gillinov SM, Islam W, Fong S, Lee AY, Abu S, Pettinelli N, Medvecky MJ, Jimenez AE. Short Symptom Duration Is Associated With Superior Outcomes in Patients Undergoing Primary Hip Arthroscopy: A Systematic Review. Arthroscopy 2023; 39:498-509. [PMID: 36395964 DOI: 10.1016/j.arthro.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/05/2022] [Accepted: 11/08/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate the effect of duration of preoperative hip pain symptoms on outcomes in patients undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement syndrome. METHODS A systematic review of the literature was conducted with the following key words: "hip arthroscopy," "outcomes," "femoroacetabular impingement," "duration," "symptoms," "time," "delay," "earlier," and "timing" was performed in PubMed and Cochrane in May 2022. The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used for this review. When available, article information including the author, study type, study period, and follow-up, demographics, preoperative duration of symptoms, surgical outcome tools, and secondary surgeries were recorded. RESULTS Six studies including 3,298 hips were included in this systematic review. Five studies had a minimum of 2 years' follow-up, and 1 study had a minimum of 5 years' follow-up. Femoroacetabular impingement (including subtypes cam and pincer impingement) was a surgical indication in all 6 studies and the most common indication for surgery. All 6 studies reported patient-reported outcome scores. All studies conducted statistical analyses comparing the duration of symptoms' effect on outcomes and found superior outcomes in patients with shorter duration of symptoms before hip arthroscopy. In 3 studies, modified Harris Hip Score, Hip Outcome Score - Activities of Daily Living, Hip Outcome Score - Sports-Specific Subscale, and visual analog scale for satisfaction ranged from 79.1-82.6, 86.3-88.4, 75-75.5. and 75.3-82.5, respectively, in cohorts with <2-year duration of symptoms, compared with 72-77.7, 79.6-84, 65.0-66.7, and 69.7-75.3 in >2-year cohort. Similarly, in one study, the <2-year duration group was reported to have a conversion to total hip arthroplasty rate of 0.6% and an overall secondary surgery rate of 0.9%, whereas the >2-year duration group had a conversion to total hip arthroplasty rate of 6.4% and an overall secondary surgery rate of 10.1%. CONCLUSIONS Patients with hip pain symptoms of less than 2 years before arthroscopic treatment of femoroacetabular impingement syndrome have better outcomes than those patients who had a longer duration of symptoms. However, significant improvements can still be expected regardless of time between onset of symptoms and surgery. LEVEL OF EVIDENCE Level IV, systematic review of Level III and Level IV studies.
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Affiliation(s)
- David Nam-Woo Kim
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Michael S Lee
- Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Ronak J Mahatme
- University of Connecticut School of Medicine, Farmington, Connecticut, U.S.A
| | - Stephen M Gillinov
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Wasif Islam
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Scott Fong
- Advanced Orthopaedics and Sports Medicine, San Francisco, California, U.S.A
| | - Amy Y Lee
- Medical College of Wisconsin, Milwaukee, Wisconsin, U.S.A
| | - Seyi Abu
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | | | - Michael J Medvecky
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Andrew E Jimenez
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, Connecticut, U.S.A.
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Yang F, Shi Y, Zhang Z, Zhang X, Huang H, Ju X, Wang J. Arthroscopy Confers Excellent Clinical Outcomes in Femoroacetabular Impingement Syndrome (FAIS) Patients Aged 50 Years and Above. Orthop Surg 2023; 15:947-952. [PMID: 36647246 PMCID: PMC10102312 DOI: 10.1111/os.13666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/12/2022] [Accepted: 12/29/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Hip preservation surgery has expanded to include treatment of hip pathology in elderly patients. Most data on efficacy of arthroscopy treatment in patients with femoroacetabular impingement syndrome (FAIS) has been generated from Western populations, while studies in the older Asian FAIS population are lacking. Here, we report efficacy of hip arthroscopy for treatment of Asian patients aged 50 years and above. METHODS We retrospectively reviewed data from 775 hips that were treated arthroscopically for FAIS between 2016 and 2019. Patients with a history of hip surgery, contralateral surgery during the follow-up period, lateral center-edge angle (LCEA) <25°, Tӧnnis grade ≥2, and incomplete records were excluded. Patient-reported outcomes (PROs), such as modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), International Hip Outcome Tool 12-component form (iHOT-12), and Visual Analog Scale (VAS) were compared pre- and post-operation. We also recorded radiographic measures, intraoperative findings, procedures, complications, and subsequent surgical revisions. Finally, we correlated demographics with PRO improvement among the study group. RESULTS A total of 57 hips met the inclusion and exclusion requirements and were therefore included in the final analysis. After the follow-up period (3.3 years), most patients exhibited significantly higher PROs than preoperative values, HOS-ADL (65.0-81.7), iHOT-12 (44.3-69.1), mHHS (58.9-81.7), and VAS (5.8-2.2; all p < 0.001). Shorter symptom duration was significantly correlated with improved HOS-ADL (p = 0.015), and mHHS score (p = 0.022). The overall rate of complications and rate of revisions were 5.3% and 7.0%, respectively, and none of the patients required total hip arthroplasty (THA). CONCLUSIONS Arthroscopic surgery confers significant clinical outcomes in most FAIS patients in the Asian population who are aged 50 years and above. These benefits are accompanied by either a low revision rate or conversion to THA, while shorter symptom duration is positively correlated with improved HOS-ADL and mHHS scores.
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Affiliation(s)
- Fan Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yuanyuan Shi
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Zhu Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xin Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hongjie Huang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xiaodong Ju
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jianquan Wang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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Ramkumar PN, Berrier AS, Helm JM, Koolmees DS, Pareek A, Krych AJ, Makhni EC, Harris JD, Nwachukwu BU. Evaluating the Need for Preoperative MRI Before Primary Hip Arthroscopy in Patients 40 Years and Younger With Femoroacetabular Impingement Syndrome: A Multicenter Comparative Analysis. Orthop J Sports Med 2023; 11:23259671221144776. [PMID: 36655021 PMCID: PMC9841845 DOI: 10.1177/23259671221144776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/26/2022] [Indexed: 01/13/2023] Open
Abstract
Background Routine hip magnetic resonance imaging (MRI) before arthroscopy for patients with femoroacetabular impingement syndrome (FAIS) offers questionable clinical benefit, delays surgery, and wastes resources. Purpose To assess the clinical utility of preoperative hip MRI for patients aged ≤40 years who were undergoing primary hip arthroscopy and who had a history, physical examination findings, and radiographs concordant with FAIS. Study Design Cohort study; Level of evidence, 3. Methods Included were 1391 patients (mean age, 25.8 years; 63% female; mean body mass index, 25.6) who underwent hip arthroscopy between August 2015 and December 2021 by 1 of 4 fellowship-trained hip surgeons from 4 referral centers. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of nonoperative management, and concomitant periacetabular osteotomy. Patients were stratified into those who were evaluated with preoperative MRI versus those without MRI. Those without MRI received an MRI before surgery without deviation from the established surgical plan. All preoperative MRI scans were compared with the office evaluation and intraoperative findings to assess agreement. Time from office to arthroscopy and/or MRI was recorded. MRI costs were calculated. Results Of the study patients, 322 were not evaluated with MRI and 1069 were. MRI did not alter surgical or interoperative plans. Both groups had MRI findings demonstrating anterosuperior labral tears treated intraoperatively (99.8% repair, 0.2% debridement, and 0% reconstruction). Compared with patients who were evaluated with MRI and waited 63.0 ± 34.6 days, patients who were not evaluated with MRI underwent surgery 6.5 ± 18.7 days after preoperative MRI. MRI delayed surgery by 24.0 ± 5.3 days and cost a mean $2262 per patient. Conclusion Preoperative MRI did not alter indications for primary hip arthroscopy in patients aged ≤40 years with a history, physical examination findings, and radiographs concordant with FAIS. Rather, MRI delayed surgery and wasted resources. Routine hip MRI acquisition for the younger population with primary FAIS with a typical presentation should be challenged.
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Affiliation(s)
- Prem N. Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women’s Hospital, Boston, Massachusetts, USA
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, USA
- Prem N. Ramkumar, MD, MBA, Department of Orthopaedic Surgery, Brigham & Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA () (Twitter: @prem_ramkumar)
| | - Ava S. Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - J. Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, USA
| | - Dylan S. Koolmees
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Ayoosh Pareek
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Aaron J. Krych
- Department of Orthopedic Surgery & Sports Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Eric C. Makhni
- Department of Orthopaedic Surgery, Henry Ford Hospital, Detroit, Michigan, USA
| | - Joshua D. Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, USA
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Larson CM. Editorial Commentary: Routine Preoperative Magnetic Resonance Imaging for Hip Arthroscopy Is Wasting Health Care Dollars and Delaying Surgical Intervention: Decision Making Should Be at the Discretion of the Health Care Provider Not Mandated by Health Care Insurers. Arthroscopy 2022; 38:3020-3022. [PMID: 36344059 DOI: 10.1016/j.arthro.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 04/22/2022] [Indexed: 11/06/2022]
Abstract
Making an accurate preoperative diagnosis is critical to optimizing outcomes after hip arthroscopy. A detailed history, thorough physical examination, imaging studies, and diagnostic injections must all be considered in the decision-making process. In today's health care climate, it is imperative to obtain essential and indicated preoperative information while being mindful of health care dollars. Magnetic resonance imaging (MRI) of the hip has been shown to be a highly sensitive modality for hip and pelvis disorders. However, it is critical to recognize that acetabular labral tears and other hip pathology are highly prevalent in an asymptomatic young adult population. There are certainly situations when an MRI should be obtained (suspected arthritic symptoms, avascular necrosis, synovial disorders, uncommon osseous tumors); however, these patients generally present with atypical symptoms. In addition, obtaining an MRI can delay surgical intervention, which has been shown to lead to inferior outcomes in prior studies. MRI is not imperative when patients present with typical intermittent, deep anterior, lateral, groin pain with prolonged sitting, twisting and pivoting, and transitioning from sitting to standing. The typical physical examination includes positive hip impingement testing (FADIR / anterior impingement test) that recreates the patients presenting complaints. Appropriate imaging includes plain radiographs revealing adequate acetabular coverage (not significantly dysplastic) or acetabular overcoverage (pincer-type femoracetabular impingement), cam-type femoracetabular impingement, and well-maintained joint space on all views, including a false profile radiograph to further evaluate the anterior joint space. Finally, a diagnostic injection can be invaluable to further confirm the hip joint proper as the source of pain. If all of the above criteria are met, I strongly believe an MRI is unlikely to alter the surgical decision-making process. In the end, the treating clinician should determine when an MRI is necessary based on the presenting symptoms and examination, rather than insurers applying a blanket requirement for preauthorization. This physician autonomy would ultimately lead to more efficient and cost-effective patient care. Medicine is an art, and unjustified handcuffing of the artist without evidence could result in inferior results.
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Ramkumar PN, Helm JM, Berrier AS, Vega JF, Yalcin S, Kunze KN, Harris JD, Nwachukwu BU. Preoperative Magnetic Resonance Imaging Offers Questionable Clinical Utility, Delays Time to Hip Arthroscopy, and Lacks Cost-Effectiveness in Patients Aged ≤40 Years With Femoroacetabular Impingement Syndrome: A Retrospective 5-Year Analysis. Arthroscopy 2022; 38:3013-3019. [PMID: 35364263 DOI: 10.1016/j.arthro.2022.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the clinical utility of preoperative magnetic resonance imaging (MRI) and quantify the delay in surgical care for patients aged ≤40 years undergoing primary hip arthroscopy with history, physical examination, and radiographs concordant with femoroacetabular impingement syndrome (FAIS). METHODS From August 2015 to December 2020, 1,786 consecutive patients were reviewed from the practice of 1 fellowship-trained hip arthroscopist. Inclusion criteria were FAIS, primary surgery, and age ≤40 years. Exclusion criteria were MRI contraindication, reattempt of conservative management, or concomitant periacetabular osteotomy. After nonoperative treatment options were exhausted and a surgical plan was established, patients were stratified by those who presented with versus without MRI. Those without existing MRI received one, and any deviations from the surgical plan were noted. All preoperative MRIs were compared with office evaluation and intraoperative findings to assess agreement. Demographic data, Hip Disability and Osteoarthritis Outcome Score (HOOS)-Pain, and time from office to MRI or arthroscopy were recorded. RESULTS Of the patients indicated by history, physical examination, and radiographs alone (70% female, body mass index 24.8 kg/m2, age 25.9 years), 198 patients presented without MRI and 934 with MRI. None of the 198 had surgical plans altered after MRI. Patients in both groups had MRI findings demonstrating anterosuperior labral tears that were visualized and repaired intraoperatively. Mean time from office to arthroscopy for patients without MRI versus those with was 107.0 ± 67 and 85.0 ± 53 days, respectively (P < .001). Time to MRI was 22.8 days. No difference between groups was observed among the 85% of patients who surpassed the HOOS-Pain minimal clinically important difference (MCID). CONCLUSION Once indicated for surgery based on history, physical examination, and radiographs, preoperative MRI did not alter the surgical plan for patients aged ≤40 years with FAIS undergoing primary hip arthroscopy. Moreover, preoperative MRI delayed time to arthroscopy. The necessity of routine preoperative MRI in the young primary FAIS population should be challenged.
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Affiliation(s)
- Prem N Ramkumar
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, Massachusetts, U.S.A.; Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A..
| | - J Matthew Helm
- Department of Orthopaedic Surgery, McGovern Medical School University of Texas Health Science Center, Houston, Texas, U.S.A
| | - Ava S Berrier
- Department of Orthopaedic Surgery, Baylor College of Medicine, Houston, Texas, U.S.A
| | - Jose F Vega
- Sports Health Center, Cleveland Clinic, Cleveland, Ohio, U.S.A
| | - Sercan Yalcin
- Department of Sports Medicine, Yale School of Medicine, New Haven, Connecticut, U.S.A
| | - Kyle N Kunze
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A
| | - Joshua D Harris
- Houston Methodist Orthopedics & Sports Medicine, Houston, Texas, U.S.A
| | - Benedict U Nwachukwu
- Center for Hip Preservation, Hospital for Special Surgery, New York, New York, U.S.A
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Yang F, Huang HJ, He ZY, Xu Y, Zhang X, Wang JQ. Extent of Cam Resection Relative to Epiphyseal Line and Its Association With Clinical Outcomes After Arthroscopic Treatment for Femoroacetabular Syndrome. Orthop J Sports Med 2022; 10:23259671221125509. [PMID: 36199833 PMCID: PMC9528010 DOI: 10.1177/23259671221125509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/27/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Inadequate resection of cam lesions can cause inferior outcomes after hip arthroscopy and result in revision surgery for femoroacetabular impingement syndrome (FAIS). Purpose: To evaluate the association between postoperative cam lesions measured using the proximal boundaries of resection area (PBRE) relative to the epiphyseal line and 2-year outcomes after hip arthroscopy. Study Design: Cohort study; Level of evidence, 3. Methods: Included were patients with FAIS who had undergone primary hip arthroscopy between 2016 and 2018. The PBRE was calculated by measuring the linear distance from the PBRE to the epiphyseal line, dividing it by the diameter of the femoral head, and multiplying by 100; PBRE measurements were made at the 12-, 1-, and 2-o’clock positions on postoperative hip computed tomography. Within each clockface position, patients were divided into subgroups depending on whether their postoperative PBRE was greater than a half standard deviation above the mean (adequate resection) or less than or equal to a half standard deviation above the mean (inadequate resection). Patient-reported outcomes (PROs; Hip Outcome Score–Activities of Daily Living [HOS-ADL], International Hip Outcome Tool–Short Form [iHOT-12], modified Harris Hip Score [mHHS], and pain visual analog scale [VAS]) and rates of achieving the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) were compared among the subgroups. Results: Included were 80 pairs of hips at 12 o’clock, 81 pairs of hips at 1 o’clock, and 80 pairs of hips at 2 o’clock. All subgroups demonstrated significant improvements in PRO scores at a minimum 2-year follow-up compared with preoperatively. At the 12-o’clock position, the subgroup with adequate resection had significantly superior HOS-ADL ( P = .004), iHOT-12 ( P < .001), and mHHS ( P < .001) scores and were more likely to achieve the MCID for the iHOT-12 score ( P = .035) and the PASS for the HOS-ADL ( P = .003), iHOT-12 ( P = .007), and mHHS ( P < .001) scores compared with the matched subgroup. There were no significant differences in PRO scores or rates of MCID and PASS for the 1- or 2-o’clock groups. Conclusion: The epiphyseal line may be a useful and reproducible landmark measurement for cam-type deformity. Patients considered to have inadequate resection at 12 o’clock had lower outcome scores at a minimum 2-year follow-up.
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Affiliation(s)
- Fan Yang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Hong-Jie Huang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Zi-Yi He
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Yan Xu
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Xin Zhang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
| | - Jian-Quan Wang
- Department of Sports Medicine, Peking University Third Hospital, Institute of Sports Medicine of Peking University, Beijing Key Laboratory of Sports Injuries, Beijing, China
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Filan D, Mullins K, MacColgáin D, Carton P. Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: Letter to the Editor. Orthop J Sports Med 2022; 10:23259671221119821. [PMID: 36081639 PMCID: PMC9445475 DOI: 10.1177/23259671221119821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Naessig S, Kucharik MP, Eberlin CT, Meek W, Cherian NJ, Martin SD. Prehabilitation and Rehabilitation Program for Patients Undergoing Arthroscopic Acetabular Labral Repair: Response. Orthop J Sports Med 2022; 10:23259671221119820. [PMID: 36081638 PMCID: PMC9445459 DOI: 10.1177/23259671221119820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Jimenez AE, Monahan PF, Owens JS, Maldonado DR, Curley AJ, Domb BG, Lall AC, Domb BG. Earlier Treatment Yields Superior Outcomes in Competitive Athletes Undergoing Primary Hip Arthroscopy. Arthroscopy 2022; 38:2183-2191. [PMID: 34915141 DOI: 10.1016/j.arthro.2021.11.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/15/2021] [Accepted: 11/30/2021] [Indexed: 02/02/2023]
Abstract
PURPOSE To report minimum 2-year patient-reported outcome scores (PROs) and return to sport (RTS) for competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome within 1 year of symptom onset and to compare these results with a propensity-matched control group of competitive athletes with symptoms for over 1 year. METHODS Data on professional, collegiate, high-school, and organized amateur athletes who underwent primary hip arthroscopy within 1 year of symptom onset between April 2008 and November 2017 were collected. RTS and minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog pain scale (VAS). Rates of achieving minimal clinically important difference (MCID) were also evaluated. These patients were propensity-matched to a control group of competitive athletes with symptoms for over one year for comparison. RESULTS Fifty competitive athletes (51 hips, 54.9% female) were included in the study group with a mean follow-up of 70.9 ± 29.1 months and age of 23.6 ± 11.3 years. They demonstrated significant improvement from preoperative to latest follow-up for all recorded PROs (P < .001) and RTS at a rate of 72.9%. When outcomes were compared to the control group, the study group demonstrated similar preoperative scores for all PROs but significantly better minimum 2-year postoperative scores for NAHS (93.8 vs 85.1, P = .0001), HOS-SSS (89.1 vs 77.2, P = .001), iHOT-12 (87.7 vs 76.4, P = 0.011), and VAS (1.5 vs 2.4, P = 0.027). Rates of achieving MCID for HOS-SSS and mHHS were comparable between groups. Further, RTS rates were similar between groups (P = .301). CONCLUSION Competitive athletes undergoing primary hip arthroscopy with symptoms for less than 1 year demonstrated superior 2-year PROs compared to a propensity-matched control group with symptoms for over 1 year, but the rates achieving MCID and RTS were similar between groups. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
| | - Peter F Monahan
- American Hip Institute Research Foundation, Chicago, Illinois
| | - Jade S Owens
- American Hip Institute Research Foundation, Chicago, Illinois
| | | | - Andrew J Curley
- American Hip Institute Research Foundation, Chicago, Illinois
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, Illinois; American Hip Institute, Chicago, Illinois; AMITA Health St. Alexius Medical Center, Hoffman Estates, Illinois, U.S.A..
| | - Ajay C Lall
- American Hip Institute Research Foundation, Chicago, IL 60018; American Hip Institute, Chicago, IL 60018; AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169
| | - Benjamin G Domb
- American Hip Institute Research Foundation, Chicago, IL 60018; American Hip Institute, Chicago, IL 60018; AMITA Health St. Alexius Medical Center, Hoffman Estates, IL 60169.
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22
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Mahmoud SSS, Takla A, Meyer D, Griffin D, O’Donnell J. Arthroscopic hip surgery offers better early patient-reported outcome measures than targeted physiotherapy programs for the treatment of femoroacetabular impingement syndrome: a systematic review and meta-analysis of randomized controlled trials. J Hip Preserv Surg 2022; 9:107-118. [PMID: 35854801 PMCID: PMC9291355 DOI: 10.1093/jhps/hnac012] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/01/2021] [Accepted: 02/10/2022] [Indexed: 02/04/2023] Open
Abstract
Targeted physiotherapy programs (TPP), and surgery, using either open surgical hip dislocation or hip arthroscopy (HA), are the treatment modalities available for femoroacetabular impingement syndrome (FAIS). Randomized controlled trials have recently been performed to compare these treatment options. This review was performed to provide a focused synthesis of the available evidence regarding the relative value of treatment options. A systematic search was performed of Medline, Embase, Cochrane Library and ClinicalTrials.gov databases. Inclusion criteria were randomized controlled trials comparing treatment methods. The Cochrane Risk of Bias assessment tool (RoB2) was used to assess the selected studies. A meta-analysis was performed between homogenous studies. Four trials were identified including 749 patients (392 males). The mean ages of the cohorts ranged between 30.1 and 36.2 years old. Three hundred thirty-five patients underwent HA by 46 surgeons among all trials. Fifty-two patients crossed over from the TPP to the HA group. One of the trials was found to have a high risk of bias, while the other three were between low risk and some concerns. The iHOT-33 was the most commonly used patient-reported outcome measure followed by the HOS ADL and EQ-5D-5L. Others scores were also identified. Scores from two trials could be pooled together for meta-analysis. Apart from SF-12 and GRC, all other scores have shown significantly better outcomes with HA in comparison to TPP at 8- and 12-months follow-up points. HA offers better patient-reported outcomes than TPP for management of FAIS at 8- and 12-months follow-up.
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Affiliation(s)
- Samer S S Mahmoud
- Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
| | - Amir Takla
- Department of Health Professions, Faculty of Health, Arts and Design, Sports & Musculoskeletal Physiotherapist, Australian Sports Physiotherapy, Swinburne University of Technology, Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
| | - Denny Meyer
- Department of Health Sciences and Biostatistics, School of Health, Swinburne University of Technology, PO Box 218, Hawthorn, VIC 3122, Australia
| | - Damian Griffin
- Department of Orthopaedic Surgery, University of Warwick, University Hospitals of Coventry and Warwickshire NHS Trust, Clifford Bridge Road, Coventry CV2 2DX, UK
| | - John O’Donnell
- Department of Orthopaedics, Swinburne University of Technology, PO Box 218, Hawthorn, VIC 3122, Australia
- Hip Arthroscopy Australia, 21 Erin Street, Richmond, VIC 3121, Australia
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23
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Kunze KN, Polce EM, Clapp IM, Alter T, Nho SJ. Association Between Preoperative Patient Factors and Clinically Meaningful Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Machine Learning Analysis. Am J Sports Med 2022; 50:746-756. [PMID: 35006010 DOI: 10.1177/03635465211067546] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND The International Hip Outcome Tool 12-Item Questionnaire (IHOT-12) has been proposed as a more appropriate outcome assessment for hip arthroscopy populations. The extent to which preoperative patient factors predict achieving clinically meaningful outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remains poorly understood. PURPOSE To determine the predictive relationship of preoperative imaging, patient-reported outcome measures, and patient demographics with achievement of the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) for the IHOT-12 at a minimum of 2 years postoperatively. STUDY DESIGN Case-control study; Level of evidence, 3. METHODS Data were analyzed for consecutive patients who underwent hip arthroscopy for FAIS between 2012 and 2018 and completed the IHOT-12 preoperatively and at a minimum of 2 years postoperatively. Fifteen novel machine learning algorithms were developed using 47 potential demographic, clinical, and radiographic predictors. Model performance was evaluated with discrimination, calibration, decision-curve analysis and the brier score. RESULTS A total of 859 patients were identified, with 685 (79.7%) achieving the MCID, 535 (62.3%) achieving the PASS, and 498 (58.0%) achieving the SCB. For predicting the MCID, discrimination for the best-performing models ranged from fair to excellent (area under the curve [AUC], 0.69-0.89), although calibration was excellent (calibration intercept and slopes: -0.06 to 0.02 and 0.24 to 0.85, respectively). For predicting the PASS, discrimination for the best-performing models ranged from fair to excellent (AUC, 0.63-0.81), with excellent calibration (calibration intercept and slopes: 0.03-0.18 and 0.52-0.90, respectively). For predicting the SCB, discrimination for the best-performing models ranged from fair to good (AUC, 0.61-0.77), with excellent calibration (calibration intercept and slopes: -0.08 to 0.00 and 0.56 to 1.02, respectively). Thematic predictors for failing to achieve the MCID, PASS, and SCB were presence of back pain, anxiety/depression, chronic symptom duration, preoperative hip injections, and increasing body mass index (BMI). Specifically, thresholds associated with lower likelihood to achieve a clinically meaningful outcome were preoperative Hip Outcome Score-Activities of Daily Living <55, preoperative Hip Outcome Score-Sports Subscale >55.6, preoperative IHOT-12 score ≥48.5, preoperative modified Harris Hip Score ≤51.7, age >41 years, BMI ≥27, and preoperative α angle >76.6°. CONCLUSION We developed novel machine learning algorithms that leveraged preoperative demographic, clinical, and imaging-based features to reliably predict clinically meaningful improvement after hip arthroscopy for FAIS. Despite consistent improvements after hip arthroscopy, meaningful improvements are negatively influenced by greater BMI, back pain, chronic symptom duration, preoperative mental health, and use of hip corticosteroid injections.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Evan M Polce
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | - Ian Michael Clapp
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas Alter
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Department of Orthopedic Surgery, Division of Sports Medicine, Rush University Medical Center, Chicago, Illinois, USA
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24
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Migliorini F, Maffulli N, Baroncini A, Eschweiler J, Tingart M, Betsch M. Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review. Am J Sports Med 2022; 50:1146-1156. [PMID: 34081552 PMCID: PMC8980457 DOI: 10.1177/03635465211011744] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear. PURPOSE To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores. STUDY DESIGN Systematic review; Level of evidence, 4. METHODS The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient. RESULTS Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA. CONCLUSION Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany,Filippo Migliorini, MD, MBA, Orthopaedics and Trauma Surgery, RWTH Aachen University Clinic, Pauwelsstraße 30, Aachen, 52074, Germany ()
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Baronissi, Italy,Queen Mary University of London, Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, London, UK,School of Pharmacy and Bioengineering, Faculty of Medicine, Keele University, Stoke on Trent, UK
| | - Alice Baroncini
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Jörg Eschweiler
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Markus Tingart
- Department of Orthopedics and Trauma Surgery, RWTH Aachen University Clinic, Aachen, Germany
| | - Marcel Betsch
- Department of Orthopaedics and Trauma Surgery, University Medical Centre Mannheim of the University Heidelberg, Mannheim, Germany
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25
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Beck EC, Nwachukwu BU, Drager J, Jan K, Rasio J, Krishnamoorthy VP, Nho SJ. Prolonged Postoperative Opioid Use After Arthroscopic Femoroacetabular Impingement Syndrome Surgery: Predictors and Outcomes at Minimum 2-Year Follow-up. Orthop J Sports Med 2021; 9:23259671211038933. [PMID: 34888387 PMCID: PMC8649101 DOI: 10.1177/23259671211038933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 05/04/2021] [Indexed: 12/05/2022] Open
Abstract
Background: The association between prolonged postoperative opioid use on outcomes after hip preservation surgery is not known. Purpose: To compare minimum 2-year patient-reported outcomes (PROs) between patients who required ≥1 postoperative opioid refill after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) versus patients who did not require a refill and to identify preoperative predictors for patients requiring ≥1 postoperative opioid refill. Study Design: Cohort study; Level of evidence, 3. Methods: Data from consecutive patients who underwent arthroscopic surgery for FAIS between January 2012 and January 2017 were analyzed. Multivariate regression analysis was performed to classify patient and radiographic variables as predictive of requiring ≥1 opioid prescription refill after surgery. Patients completed the following PROs preoperatively and at 2-year follow-up: Hip Outcome Score— Activities of Daily Living subscale (HOS-ADL), HOS–Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-12), and 100-point visual analog scale (VAS) for pain and satisfaction. Scores were compared between patients needing additional prescription opioids and those who did not. Results: A total of 775 patients, of whom 141 (18.2%) required ≥1 opioid prescription refill, were included in the analysis. Patients requiring opioid refills had significantly lower 2-year postoperative PRO scores compared with patients not requiring refills: HOS-ADL (79.9 ± 20.3 vs 88.7 ± 14.9), HOS-SS (64.6 ± 29.5 vs 78.2 ± 23.7), mHHS (74.2 ± 21.1 vs 83.6 ± 15.9), iHOT-12 (63.6 ± 27.9 vs 74.9 ± 24.8), and VAS satisfaction (73.4 ± 30.3 vs 82.2 ± 24.9), as well as significantly more pain (26.8 ± 23.4 vs 17.9 ± 21.8) (P ≤ .001 for all). Predictors of requiring a postoperative opioid refill included patients with active preoperative opioid use (odds ratio, 3.12 [95% confidence interval, 1.06-9.21]; P = .039) and larger preoperative alpha angles (odds ratio, 1.04 [95% confidence interval, 1.01-1.07]; P = .03). Conclusion: Patients requiring ≥1 opioid prescription refill after hip arthroscopy for FAIS had lower preoperative and 2-year PRO scores when compared with patients not requiring refills. Additionally, active opioid use at the time of surgery was found to be predictive of requiring additional opioids for pain management.
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Affiliation(s)
- Edward C Beck
- Department of Orthopaedic Surgery, Wake Forest Baptist Health, Winston-Salem, North Carolina, USA
| | - Benedict U Nwachukwu
- Division of Sports Medicine Surgery, Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York, USA
| | - Justin Drager
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Kyleen Jan
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Jonathan Rasio
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Vignesh P Krishnamoorthy
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Division of Sports Medicine Surgery, Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois, USA
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26
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Vahedi H, Yacovelli S, Diaz C, Parvizi J. Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure. JB JS Open Access 2021; 6:JBJSOA-D-20-00176. [PMID: 34841187 PMCID: PMC8613364 DOI: 10.2106/jbjs.oa.20.00176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair.
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Affiliation(s)
- Hamed Vahedi
- West Virginia University Medicine, Morgantown, West Virginia
| | - Steven Yacovelli
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Claudio Diaz
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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27
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Terrell SL, Olson GE, Lynch J. Therapeutic Exercise Approaches to Nonoperative and Postoperative Management of Femoroacetabular Impingement Syndrome. J Athl Train 2021; 56:31-45. [PMID: 33112956 DOI: 10.4085/1062-6050-0488.19] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Femoroacetabular impingement syndrome (FAIS) is characterized by premature contact of the femur and acetabulum during hip motion. Morphologic variations of FAIS present as either aspherical femoral deformity (cam femoroacetabular impingement) or overcoverage (pincer femoroacetabular impingement) or both. Patients with FAIS often describe discomfort with hip flexion, adduction, and internal rotation. The use of hip arthroscopy to treat FAIS has risen substantially over the last 15 years. Given that one practice domain of the athletic training profession involves injury prevention and wellness protection, optimal FAIS treatment and management strategies warrant discussion. Sports medicine professionals often help patients with FAIS explore nonoperative exercise strategies and direct rehabilitation exercises for those who pursue surgery. Both approaches demonstrate key pillars of exercise program design, which include postural control, core stabilization, hip strength and motor control, and mobility. The purpose of this article is 2-fold: to present an overview of FAIS, including common diagnostic strategies, and commonalities in therapeutic approaches between nonoperative and postoperative rehabilitation for the treatment and management of patients with FAIS.
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Affiliation(s)
- Sara Lynn Terrell
- Department of Exercise Science, Florida Southern College, Lakeland.,School of Nursing and Health Sciences, Florida Southern College, Lakeland
| | - Gayle E Olson
- Department of Athletics, Florida Southern College, Lakeland
| | - James Lynch
- School of Nursing and Health Sciences, Florida Southern College, Lakeland
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28
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Patient outcomes after direct capsular closure following hip arthroscopy: a systematic review. CURRENT ORTHOPAEDIC PRACTICE 2021. [DOI: 10.1097/bco.0000000000001013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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29
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Kunze KN, Alter TD, Newhouse AC, Bessa FS, Williams JC, Nho SJ. Association Between Orientation and Magnitude of Femoral Torsion and Propensity for Clinically Meaningful Improvement After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Computed Tomography Analysis. Am J Sports Med 2021; 49:2466-2474. [PMID: 34166125 DOI: 10.1177/03635465211021610] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Femoral torsion imaging measurements and classifications are heterogeneous throughout the literature, and the influence of femoral torsion on clinically meaningful outcome improvement after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) has not been well studied. PURPOSE To (1) perform a computed tomography (CT)-based analysis to quantify femoral torsion in patients with FAIS and (2) explore the relationship between the orientation and magnitude of femoral torsion and the propensity for clinically meaningful outcome improvement after hip arthroscopy. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Consecutive patients who underwent hip arthroscopy for FAIS between January 2012 and April 2018 were identified. Inclusion criteria were the presence of preoperative CT imaging with transcondylar slices of the knee and minimum 2-year outcome measures. Exclusion criteria were revision hip arthroscopy, Tönnis grade >1, congenital hip condition, hip dysplasia (lateral center-edge angle <20°), and concomitant gluteus medius or minimus repair. Torsion groups were defined as severe retrotorsion (SR; <0°), moderate retrotorsion (MR; 0°-5°), normal torsion (N; 5°-20°), moderate antetorsion (MA; 20°-25°), and severe antetorsion of antetorsion (SA; >25°). Treatment did not differ based on femoral torsion. Patient characteristics and clinical outcomes were analyzed, including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), visual analog scale (VAS) for pain, and VAS for satisfaction. Achievement of the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) by torsion stratification was analyzed using the chi-square test. Inter- and intrarater reliabilities for CT measurements were 0.980 (P < .001) and 0.974 (P < .001), respectively. RESULTS The study included 573 patients with a mean ± SD age and body mass index of 32.6 ± 11.8 years and 25.6 ± 10.6, respectively. The mean ± SD femoral torsion for the study population was 12.3°± 9.3°. After stratification, the number of patients within each group and the mean ± SD torsion for each group were as follows: SR (n = 36; -6.5°± 7.1°), MR (n = 80; 2.8°± 1.4°), N (n = 346; 12.3°± 4.1°), MA (n = 64; 22.2°± 1.4°), and SA (n = 47; 30.3°± 3.7°). No significant differences in age, body mass index, sex, tobacco use, workers' compensation status, or participation in physical activity were observed at baseline. No significant differences were seen in pre- and postoperative VAS pain, mHHS, HOS-ADL, HOS-SS, iHOT-12, or postoperative VAS satisfaction among the cohorts. Furthermore, no statistically significant differences were found in the proportion of patients who achieved the MCID or the PASS for any outcome among the groups. CONCLUSION The orientation and severity of femoral torsion at the time of hip arthroscopy for FAIS did not influence the propensity for clinically significant outcome improvement.
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Affiliation(s)
- Kyle N Kunze
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA.,Hospital for Special Surgery, Department of Orthopedic Surgery, New York, New York, USA
| | - Thomas D Alter
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Alexander C Newhouse
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Felipe S Bessa
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Joel C Williams
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopaedic Surgery, Hip Preservation Center, Rush University Medical Center, Chicago, Illinois, USA
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30
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Spiker AM. Editorial Commentary: Hip Arthroscopy Evolution and Causes of Failure. Arthroscopy 2021; 37:1829-1832. [PMID: 33745935 DOI: 10.1016/j.arthro.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 03/11/2021] [Indexed: 02/02/2023]
Abstract
Hip arthroscopy use has grown as a result of expanding indications; improved imaging including higher resolution magnetic resonance imaging with stronger magnetic fields and the advent of 3-dimensional computed tomography revealing the nuances of hip joint morphology; increased specialized training; improvements in instruments and implants; a record of successful outcomes; and increased understanding of microinstability, focal acetabular undercoverage or occult dysplasia, indications for labral reconstruction and capsular plication, and, most of all, femoroacetabular impingement syndrome, the leading diagnosis for which hip arthroscopy is performed, in the orthopaedic community as well as the general medical and athletic communities. We now know that labral repair results in better outcomes than labral debridement, and evidence suggests that capsule closure leads to better long-term success. Osteoarthritis and its correlate, advanced age, result in inferior survivorship after hip arthroscopy, which is unsurprising; hip preservation surgery is not designed to treat irreparable cartilage damage. Association of female sex with hip arthroscopy failure requires additional investigation. More females undergo hip arthroscopy than males, and females initially present with greater disability. Females tend to have smaller alpha angles, greater femoral and acetabular anteversion, and lower center edge angles than males, consistent with increased prevalence of hip dysplasia. Thus surgeons indicating females for hip arthroscopy should be aware of atypical locations of cam lesions, borderline dysplasia, or ligamentous laxity, all of which must be appropriately respected at the time of surgery. With all of the improvements we have made in techniques, patient diagnosis and surgical indications, and our overall understanding of complex anatomy and a technically challenging surgery, we can speculate that our long-term survivorship will only improve. I await with interest the long-term outcomes we will see 10 years from today, with the addition of insight from patient-reported outcome measures to answer these questions with greater certainty.
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31
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Akpinar B, Lin LJ, Bloom DA, Youm T. Hip Arthroscopy for Femoroacetabular Impingement: Minimal Clinically Important Difference Rates Decline From 1- to 5-Year Outcomes. Arthrosc Sports Med Rehabil 2021; 3:e351-e358. [PMID: 34027442 PMCID: PMC8129050 DOI: 10.1016/j.asmr.2020.09.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 09/23/2020] [Indexed: 01/11/2023] Open
Abstract
Purpose To correlate patient-reported outcomes (PROs) and minimal clinically important difference (MCID) achievement rates after hip arthroscopy for femoroacetabular impingement syndrome (FAI). Methods Patients with clinically diagnosed FAI who underwent primary hip arthroscopy from September 2012 to March 2014 with a minimum of 5-year outcomes were identified. Patients undergoing labral debridement, microfracture, bilateral procedures, with evidence of dysplasia, Tönnis grade >1, and joint space <2 mm were excluded. Analysis of variance was used to compare PROs. Survival rates were determined using Kaplan–Meier analysis. Regression analysis identified associations with modified Harris Hip Scores (mHHS), minimal clinically important difference (MCID) rates, and Nonarthritic Hip Scores (NAHS). Results A total of 85 of 101 eligible consecutive patients (84% inclusion) (age: 41.4 ± 14.0 years; 69% female, mean body mass index [BMI] 25.0 ± 4.2) met inclusion and exclusion criteria. Patients underwent labral repair (100%) and a combination of cam (86%) and pincer resection (99%). The 5-year survival-to-revision rate was 77% whereas 5-year survival rate to total hip arthroplasty was 94%. The 1-year (87.4 ± 13.6) and 5-year (84.5 ± 13.5) mHHS scores were greater versus preoperative scores (46.3 ± 11.3, P < .001). There was a decrease in MCID rate between 1-year (n = 74, 87%) and 5-year (n = 61, 73%, P = .019) outcomes. The 1-year (87.4 ± 12.7) and 5-year (89.2 ± 15.8) NAHS scores were greater versus preoperative scores (49.7 ± 12.7, P < .001). Regression demonstrated associations between BMI (MCID: P = .033; NAHS: P = .010), age (mHHS: P = .031), and cam resection (mHHS: P = .010) with 5-year outcomes. Conclusions There is a decline in MCID at 5-year follow-up after hip arthroscopy for FAI. Lower BMI, younger age, and cam resection are associated with positive outcomes. There is excellent index procedure survivability and excellent total hip arthroplasty prevention rate. Level of Evidence Level IV.
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Affiliation(s)
| | - Lawrence J Lin
- NYU Langone Orthopedic Hospital, New York, New York, U.S.A
| | - David A Bloom
- NYU Langone Orthopedic Hospital, New York, New York, U.S.A
| | - Thomas Youm
- NYU Langone Orthopedic Hospital, New York, New York, U.S.A
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Zimmerer A. A Multicenter Study of Radiographic Measures Predicting Failure of Arthroscopy in Borderline Hip Dysplasia: Letter to the Editor. Am J Sports Med 2021; 49:NP19-NP20. [PMID: 33929881 DOI: 10.1177/03635465211005720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Oji NM, Jansson H, Bradley KE, Feeley BT, Zhang AL. Comparing Patient-Reported Outcome Measurements for Femoroacetabular Impingement Syndrome. Am J Sports Med 2021; 49:1578-1588. [PMID: 33739894 DOI: 10.1177/0363546521999403] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND There is much debate in the current literature with regard to the most appropriate hip-specific patient-reported outcome (PRO) measurement for assessment of femoroacetabular impingement syndrome (FAIS) and outcomes after surgical treatment. Despite systematic reviews assessing the validity of classic hip-specific PROs as well as newer PROs developed to target the young, active population, there lacks a direct comparison of the question content between each PRO. PURPOSE To compare the question composition and degree of overlap between commonly used PROs for FAIS. STUDY DESIGN Cross-sectional study. METHODS A literature review yielded the 6 most commonly cited PROs for assessment of FAIS: modified Harris Hip Score (mHHS), Hip disability and Osteoarthritis Outcome Score (HOOS), Copenhagen Hip and Groin Outcome Score (HAGOS), Nonarthritic Hip Score (NAHS), international Hip Outcome Tool (iHOT-33), and Hip Outcome Score (HOS). Questions from each PRO were classified as identical, similar, or unique after pooled comparison, and the number of overlapping (identical or similar) questions between each PRO was determined. Questions were then classified into 5 domains: pain, symptoms, functional activities, sports, and quality of life, and variations in questions assessing each domain based on PRO were analyzed. RESULTS Analysis of 164 total questions from 6 PROs showed that 87 questions (53%) were identical between 2 or more PROs, 39 (24%) were similar, and 38 (23%) were unique. The iHOT-33 contained the highest number of unique questions, with 13 of 33 (39.4%), while the HOOS contained the lowest number of unique questions, with 3 of 40 (7.5%). The HOOS, HAGOS, and iHOT-33 contained questions assessing all 5 domains of patient outcomes; the NAHS did not evaluate quality of life; the mHHS only assessed pain, symptoms, and functional activities; and the HOS only assessed functional activities and sports. CONCLUSION As there is a high percentage of overlapping (identical or similar) questions between the most commonly used hip-specific PROs for FAIS, multiple tests may be appropriate for use. The iHOT-33, HOOS, and HAGOS are well suited for the general population as they offer comprehensive assessments across all domains, while the HOS provides added focus to sports/activity assessments for athletes and highly active patients.
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Affiliation(s)
- Nnaoma M Oji
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Hayley Jansson
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Kendall E Bradley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California, USA
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Kunze KN, Polce EM, Nwachukwu BU, Chahla J, Nho SJ. Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting Clinically Significant Functional Improvement in a Mixed Population of Primary Hip Arthroscopy. Arthroscopy 2021; 37:1488-1497. [PMID: 33460708 DOI: 10.1016/j.arthro.2021.01.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 12/30/2020] [Accepted: 01/03/2021] [Indexed: 02/06/2023]
Abstract
PURPOSE To (1) develop and validate a machine learning algorithm to predict clinically significant functional improvements after hip arthroscopy for femoroacetabular impingement syndrome and to (2) develop a digital application capable of providing patients with individual risk profiles to determine their propensity to gain clinically significant improvements in function. METHODS A retrospective review of consecutive hip arthroscopy patients who underwent cam/pincer correction, labral preservation, and capsular closure between January 2012 and 2017 from 1 large academic and 3 community hospitals operated on by a single high-volume hip arthroscopist was performed. The primary outcome was the minimal clinically important difference (MCID) for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) at 2 years postoperatively, which was calculated using a distribution-based method. A total of 21 demographic, radiographic, and patient-reported outcome measures were considered as potential covariates. An 80:20 random split was used to create training and testing sets from the patient cohort. Five supervised machine learning algorithms were developed using 3 iterations of 10-fold cross-validation on the training set and assessed by discrimination, calibration, Brier score, and decision curve analysis on an independent testing set of patients. RESULTS A total of 818 patients with a median (interquartile range) age of 32.0 (22.0-42.0) and 69.2% female were included, of whom 74.3% achieved the MCID for the HOS-ADL. The best-performing algorithm was the stochastic gradient boosting model (c-statistic = 0.84, calibration intercept = 0.20, calibration slope = 0.83, and Brier score = 0.13). Of the initial 21 candidate variables, the 8 most important features for predicting the MCID for the HOS-ADL included in model training were body mass index, age, preoperative HOS-ADL score, preoperative pain level, sex, Tönnis grade, symptom duration, and drug allergies. The algorithm was subsequently transformed into a digital application using local explanations to provide customized risk assessment: https://orthoapps.shinyapps.io/HPRG_ADL/. CONCLUSIONS The stochastic boosting gradient model conferred excellent predictive ability for propensity to gain clinically significant improvements in function after hip arthroscopy. An open-access digital application was created, which may augment shared decision-making and allow for preoperative risk stratification. External validation of this model is warranted to confirm the performance of these algorithms, as the generalizability is currently unknown. LEVEL OF EVIDENCE IV, Case series.
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Affiliation(s)
- Kyle N Kunze
- Department of Orthopedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A..
| | - Evan M Polce
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Benedict U Nwachukwu
- Department of Orthopedic Surgery, Division of Sports Medicine, Hospital for Special Surgery, New York, New York, U.S.A
| | - Jorge Chahla
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
| | - Shane J Nho
- Section of Young Adult Hip Surgery, Division of Sports Medicine, Department of Orthopedic Surgery, Rush Medical College of Rush University, Rush University Medical Center, Chicago, Illinois
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Lindman I, Nikou S, Öhlin A, Senorski EH, Ayeni O, Karlsson J, Sansone M. Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review. J Exp Orthop 2021; 8:33. [PMID: 33893563 PMCID: PMC8065071 DOI: 10.1186/s40634-021-00351-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/08/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included. METHODS This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs. RESULTS The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%). CONCLUSION There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.
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Affiliation(s)
- Ida Lindman
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden.
| | - Sarantos Nikou
- Department of Orthopaedic Surgery, South Älvsborg Hospital, 501 82, Borås, Sweden
| | - Axel Öhlin
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
| | - Eric Hamrin Senorski
- Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Olufemi Ayeni
- Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, L8N 3Z5, Canada
| | - Jon Karlsson
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
| | - Mikael Sansone
- Department of Orthopaedics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, 413 45, Gothenburg, Sweden
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Make the Right Diagnosis: My Pearls for Working Up Hip-related Pain. Sports Med Arthrosc Rev 2021; 29:2-8. [PMID: 33395223 DOI: 10.1097/jsa.0000000000000288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The origin of pain around the hip is commonly more elusive than other joints; often obscured by compensatory disorders. Hip problems tend to be multifactorial and require a multidisciplinary approach in the evaluation. The best strategy is to team with a capable physical therapist to unveil the layers of problems. Ultrasonography and imaging/ultrasound-guided injections can be the most valuable adjunct to the history and physical examination. Plain radiographs are an essential element in the workup. Magnetic resonance imaging can underestimate damage in the joint, but positive findings can sometimes be the normal consequence of age and activity. Magnetic resonance imaging is often as important for what it rules out as much as what it rules in. Computed tomography scans with 3-dimensional reconstructions can be especially helpful in surgical planning but are not used in routine screening, being thoughtful of radiation exposure even with low-dose protocols. Arthroscopic access to the hip is more challenging than other joints, and similarly, unlocking its clinical secrets can be more imposing as well.
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Takla A, O'Donnell J, Voight M, Byrd T, Dienst M, Martin RR, Philippon MJ, Enseki K, Andrade T, Safran M, Christoforetti JJ, Martin H, Grant L, Campbell A, Ryan M, Tyler T, McGovern RP, Bizzini M, Kohlrieser D. The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on assessment and treatment of femoroacetabular impingement syndrome (FAIS): an international consensus statement. J Hip Preserv Surg 2021; 7:631-642. [PMID: 34377507 PMCID: PMC8349584 DOI: 10.1093/jhps/hnaa043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/30/2020] [Accepted: 08/15/2020] [Indexed: 12/11/2022] Open
Abstract
The 2019 International Society of Hip Preservation (ISHA) physiotherapy agreement on femoroacetabular impingement syndrome (FAIS) was intended to build an international physiotherapy consensus on the assessment, non-surgical physiotherapy treatment, pre-/post-operative management, and return to sport decisions for those patients with FAIS. The panel consisted of 11 physiotherapists and 8 orthopaedic surgeons. There is limited evidence regarding the use of physiotherapy in the overall management of those with FAIS. Therefore, a group of ISHA member physiotherapists, who treat large numbers of FAIS patients and have extensive experience in this area, constructed a consensus statement to guide physiotherapy-related decisions in the overall management of those with FAIS. The consensus was conducted using a modified Delphi technique. Six major topics were the focus of the consensus statement: (i) hip assessment, (ii) non-surgical physiotherapy management, (iii) pre-habilitation prior to hip arthroscopy, (iv) post-operative physiotherapy rehabilitation, (v) stages of post-operative rehabilitation and (vi) return to sports criteria/guidelines after surgery.
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Affiliation(s)
- Amir Takla
- Swinburne University of Technology - Hawthorn Campus, Health Science, Hawthorn, VIC, Australia.,Australian Sports Physiotherapy - Ivanhoe, 3079, Australia.,Hip Arthroscopy Australia, Melbourne, Richmond, VIC 3121, Australia
| | - John O'Donnell
- Hip Arthroscopy Australia, Melbourne, Richmond, VIC 3121, Australia.,Orthopaedic, St Vincent's Melbourne, East Melbourne, VIC 3054, Australia
| | - Michael Voight
- Physical Therapy, Nashville Hip Institute, Nashville, TN 37203, USA.,Physical Therapy, Belmont University, Nashville, TN 37212-3757, USA
| | - Thomas Byrd
- Surgery, Nashville Sports Medicine Foundation, Nashville, TN, USA
| | - Michael Dienst
- OCM Orthopädische Chirurgie München, Steinerstr. 6, Munich, 81369, Germany
| | - Rob Roy Martin
- Physical Therapy, Duquesne University, Pittsburgh, PA 15282-0001, USA
| | - Marc J Philippon
- Steadman Philippon Research Institute, COOR, Vail, CO 81657-5242, USA
| | - Keelan Enseki
- University of Pittsburgh Medical Center, Rooney Sports Complex, Pittsburgh, PA, USA
| | - Tony Andrade
- Reading Orthopaedic Centre, Circle Reading Hospital, Reading RG2 0NE, UK.,Trauma and Orthopaedic Department, Royal Berkshire NHS Foundation Trust, Reading RG1 5AN, UK
| | - Marc Safran
- Orthopaedic Surgery, Stanford University, Redwood City, CA 94063, USA
| | | | - Hal Martin
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, TX 75246-2088, USA
| | | | - Ashley Campbell
- Physical Therapy, Belmont University, Nashville, TN 37212-3757, USA
| | - Mark Ryan
- University of Pittsburgh Medical Center, Rooney Sports Complex, Pittsburgh, PA, USA
| | - Tim Tyler
- Physiotherapy, Pro Sports Physical Therapy, New York, USA
| | - Ryan P McGovern
- Texas Health Sports Medicine, Sports Medicine Research, Allen, TX 15013, USA
| | - Mario Bizzini
- Physiotherapy, Schulthess Klinik, Zurich, Switzerland
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Large Heterogeneity Among Minimal Clinically Important Differences for Hip Arthroscopy Outcomes: A Systematic Review of Reporting Trends and Quantification Methods. Arthroscopy 2021; 37:1028-1037.e6. [PMID: 33186696 DOI: 10.1016/j.arthro.2020.10.050] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/18/2020] [Accepted: 10/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To perform a systematic review of reporting trends and quantification methods for the minimal clinically important difference (MCID) within the hip arthroscopy literature. METHODS Cochrane, PubMed, and OVID/MEDLINE databases were queried for hip arthroscopy articles that reported the MCID. Studies were classified as (1) calculating new MCID values for their specific study-population or (2) referencing previously established MCID values. Data pertaining to patient demographics, study characteristics, outcome measures, method of MCID quantification, MCID value, anchor questions, measurement error, and study from which referenced MCID values were obtained were extracted. RESULTS A total of 59 articles with 18,830 patients (19,867 hips) was included. A total of 19 unique outcome measures was reported. A total of 33 (n = 55.9%) studies (follow-up range 6-60 months) used previously established MCID values to assess their study population (MCID values established at a follow-up range 6-31 months). The remaining 26 studies (44.1%) performed new MCID calculations. The MCID values were inconsistent and varied widely (Hip Outcome Score-Activities of Daily Living: 5.0-15.4; Hip Outcome Score-Sports Subscale: 6-25; modified Harris hip score: 2.4-20.9). Among the 33 studies that used previously established MCID values, 10 different studies were cited as the reference. Among the remaining 26 studies that calculated a new MCID value, the most common method was 0.5 standard deviation method (n = 21, 80.8%). Only 3 of 26 (11.5%) studies reported a measurement of error in conjunction with their MCID values. CONCLUSIONS Inconsistencies in MCID reporting and quantification methods led to a wide range of MCID values for commonly administered outcome measures within the hip arthroscopy literature-even for the same outcome measures. The majority of studies referenced previously established MCID values with variable ranges of follow-up and applied those values to assess their specific study population at varying follow-ups. LEVEL OF EVIDENCE IV, systematic review.
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Yang F, Mamtimin M, Duan YP, Sun H, Xu Y, Zhang X, Zheng XY, Fan JL, Huang HJ, Wang JQ. Volume of Gluteus Maximus and Minimus Increases After Hip Arthroscopy for Femoroacetabular Impingement Syndrome. Arthroscopy 2021; 37:862-870. [PMID: 33524479 DOI: 10.1016/j.arthro.2020.10.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 10/28/2020] [Accepted: 10/30/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To investigate the change in muscle volume around the hip in patients with femoroacetabular impingement (FAI) after arthroscopy and evaluate other factors related to muscle change. METHODS We performed a retrospective review of magnetic resonance imaging data of patients with FAI who underwent hip arthroscopy. Magnetic resonance imaging was obtained pre- and postoperatively. The cross-sectional area (CSA) of muscles were determined on axial images. The Wilcoxon signed-rank test was used to determine the differences between pre- and postoperative hip muscle CSA. The correlations of change in muscle CSA with age, sex, body mass index, pain level, preoperative symptom duration, follow-up time, and multiple validated patient-reported outcomes were also analyzed with a Spearman rank correlation test. RESULTS Fifty-one patients with a mean age of 36.5 ± 5.6 years were included and analyzed. The follow-up was 26.6 ± 0.5 months (range, 24-40 months), and 27 (52.9%) were women. Patients with FAI showed increased hip muscle CSA of gluteus maximus (P = .002) and gluteus minimus (P = .001). Post- compared with preoperative, the value for the change in medius CSA was underpowered, and no differences in other hip muscle CSAs were observed. The increased muscle CSA of the gluteus maximus was significantly correlated with the improvement of modified Harris Hip Score (ρ = 0.404; P = .003). The increased muscle CSA of the gluteus minimus was significantly correlated with the improvement of pain Visual Analog Scale (ρ = 0.452; P = .001). Age, body mass index, sex, symptom duration, and follow-up time were not significantly correlated with change in muscle CSA. CONCLUSIONS Patients with FAI have a significantly increased postoperative muscle CSA of the gluteus maximus (7.8%) and the gluteus minimus (11.6%) compared with preoperative values. The increased muscle CSA of the gluteus maximus and gluteus minimus was significantly correlated with improvement in modified Harris Hip Score and pain Visual Analog Scale, respectively. The increase of muscle volume may be associated with the improvement of subjective function and pain relief. LEVELS OF EVIDENCE Level IV, therapeutic case series.
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Affiliation(s)
- Fan Yang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Mahmut Mamtimin
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Yu-Peng Duan
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Hao Sun
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Yan Xu
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xin Zhang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Xiao-Yan Zheng
- Department of Agroforestry and Medicine, The Open University of China, Beijing, China
| | - Jia-Lin Fan
- Department of Medical Statistics, Chinese PLA General Hospital, Beijing, China
| | - Hong-Jie Huang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China
| | - Jian-Quan Wang
- Institute of Sports Medicine, Beijing Key Laboratory of Sports Injuries, Peking University Third Hospital, Beijing, China.
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Abstract
Femoroacetabular impingement and associated labral tearing is a common source of hip pain in athletes. This article reviews the hip joint anatomy and complex interplay between alterations on the femoral and acetabular sides, in addition to evaluation of soft tissue stabilizers and spinopelvic parameters. Symptom management with a focus on arthroscopic treatment of abnormal bony morphology and labral repair or reconstruction is discussed. In select patients with persistent pain who have failed conservative measures, hip arthroscopy with correction of bony impingement and labral repair or reconstruction has yielded good to excellent results in recreational and professional athletes.
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Block AM, Minaie A, Ross JR, Clohisy JC, Nepple JJ. Insurance Coverage Criteria for Femoroacetabular Impingement Surgery: Are They Responding to Improving Evidence? THE IOWA ORTHOPAEDIC JOURNAL 2021; 41:145-154. [PMID: 34552417 PMCID: PMC8259176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
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.
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Affiliation(s)
- Andrew M. Block
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Arya Minaie
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - James R. Ross
- Broward Orthopedic Specialists, Fort Lauderdale, FL, USA
| | - John C. Clohisy
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | | | - Jeffrey J. Nepple
- Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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Akpinar B, Lin LJ, Bloom DA, Youm T. Hip Arthroscopy for Femoroacetabular Impingement: 1-Year Outcomes Predict 5-Year Outcomes. Am J Sports Med 2021; 49:104-111. [PMID: 33151747 DOI: 10.1177/0363546520968562] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited evidence exists comparing short- and long-term patient-reported outcomes (PROs) and overall survival rates after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). HYPOTHESIS Patients with high improvement (HI) versus low improvement (LI) at 1 year postoperatively would achieve higher PROs and better index procedure survival rates at 5-year follow-up. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS Patients who underwent primary hip arthroscopy for FAIS between September 2012 and March 2014 with minimum 5-year outcome data were identified. Using the median 1-year change in modified Harris Hip Score (mHHS) as a threshold, HI and LI subcohorts were determined. Analysis of variance was used to compare PROs. Failure rates were determined using Kaplan-Meier and Cox proportional hazards model analyses. Regression analysis was used to identify factors associated with increasing 5-year change in mHHS and Nonarthritic Hip Score (NAHS). RESULTS Out of 108 eligible consecutive patients, 89 (82.4%) were included (mean [SD]: age, 43.3 [14.6] years; body mass index, 25.4 [4.5]). As compared with the LI group (n = 45), the HI group (n = 44) had a longer 5-year index surgery survival rate (mean ± SEM: 83.7 ± 3.3 months vs 68.5 ± 4.6 months; P = .012) and 5-year estimated survival rate (89% vs 71%). The HI group had a decreased risk of failure versus the LI group (hazard ratio, 0.15; P = .002). The HI group also had greater PROs than did the LI group at 1 year (mHHS: 94.8 ± 1.2 vs 72.6 ± 2.7, P < .001; NAHS: 94.0 ± 1.3 vs 75.6 ± 2.2, P < .001) and 5 years (mHHS: 86.9 ± 2.0 vs 77.6 ± 3.4, P = .017; NAHS: 92.6 ± 1.8 vs 82.7 ± 4.1, P = .020). As compared with the LI group, the HI group achieved higher rates of the Patient Acceptable Symptomatic State (PASS) and minimal clinically important difference (MCID) at 1 year (PASS: 95% vs 42%, P < .001; MCID: 100% vs 89%, P = .056) and 5 years (PASS: 77% vs 45%, P = .002; MCID: 86% vs 64%, P = .014). Linear regression demonstrated that being in the HI group (ΔmHHS, P = .041; ΔNAHS, P = .017) and decreasing body mass index (ΔmHHS, P = .055; ΔNAHS, P = .023) were associated with higher 5-year ΔPROs. CONCLUSION Patients with FAIS and significant improvement in the first year after hip arthroscopy had superior 5-year outcomes versus patients with persistent symptom severity. Survival rates and PROs were significantly better in patients who achieved high early outcomes at the 1-year mark.
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Affiliation(s)
| | - Lawrence J Lin
- NYU Langone Orthopedic Hospital, New York, New York, USA
| | - David A Bloom
- NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Thomas Youm
- NYU Langone Orthopedic Hospital, New York, New York, USA
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Lin LJ, Akpinar B, Bloom DA, Youm T. Age and Outcomes in Hip Arthroscopy for Femoroacetabular Impingement: A Comparison Across 3 Age Groups. Am J Sports Med 2021; 49:82-89. [PMID: 33237816 DOI: 10.1177/0363546520974370] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Limited evidence exists concerning the effect of age on hip arthroscopy outcomes for femoroacetabular impingement (FAI). PURPOSE/HYPOTHESIS The purpose was to investigate patient-reported outcomes (PROs) and clinical failure rates across various age groups in patients undergoing hip arthroscopy for FAI. We hypothesized that older patients would experience lower improvements in PROs and higher clinical failure rates. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A total of 109 of 130 eligible consecutive patients underwent hip arthroscopy for FAI with a minimum 5-year follow-up. Patients were stratified into 3 groups for comparison (ages 15-34, 35-50, and 51-75 years). Clinical survival rates to revision surgery or total hip arthroplasty (THA) were determined by Kaplan-Meier analysis, and PROs were assessed using analysis of variance. Regression analysis was used to determine factors associated with clinical failure and ΔPROs from baseline to 5 years. RESULTS The 5-year survival-to-revision rate was 71% (survival time, 69.2 months; 95% CI, 62.8 to 75.5 months). A significant difference in survival to THA was found between groups (P = .030). Being in the older group versus the young and middle-aged groups predicted increased risk of THA conversion (hazard ratio, 5.7; 95% CI, 1.1 to 28.6; P = .035). Overall modified Harris Hip Score (mHHS) and Nonarthritic Hip Score (NAHS) improved from baseline to 5 years (mHHS, P < .001; NAHS, P < .001). Body mass index (mHHS: beta, -1.2; 95% CI, -2.2 to -0.3; P = .013; NAHS: beta, -1.6; 95% CI, -2.6 to -0.5; P = .005) and baseline PROs (mHHS: beta, -0.8; 95% CI, -1.1 to -0.4; P < .001; NAHS: beta, -0.7; 95% CI, -1.1 to -0.4; P < .001) were predictive of 5-year ΔPROs. A decrease was seen in minimal clinically important difference rates in middle-aged (P = .011) and old (P = .030) groups from 6-month to 5-year outcomes. CONCLUSION Although hip arthroscopy for FAI yielded improvements in PROs regardless of age, middle-aged and older patients experienced greater declines in clinical outcomes over time than younger patients. Older patients remain good candidates for arthroscopy despite a greater risk for conversion to THA.
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Affiliation(s)
- Lawrence J Lin
- NYU Langone Orthopedic Hospital, New York, New York, USA
| | | | - David A Bloom
- NYU Langone Orthopedic Hospital, New York, New York, USA
| | - Thomas Youm
- NYU Langone Orthopedic Hospital, New York, New York, USA
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Cao J, Chen D. [Research progress in arthroscopic treatment of acetabular labrum injury]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:1607-1611. [PMID: 33319544 DOI: 10.7507/1002-1892.202002161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To review the surgical methods of arthroscopy in the treatment of acetabular labrum injury, and to provide reference for clinical treatment. Methods The literature about the surgical methods and clinical results of hip arthroscopy in the treatment of acetabular labrum injury was reviewed and analyzed. Results In the early stages of hip arthroscopy, the removal of the torn labrum is the primary treatment option. The current principles of treatment are based on the specific circumstances of a torn labrum, including acetabular labrum debridement, acetabular labrum repair, acetabular labrum reconstruction, and acetabular labrum augmentation. Conclusion Hip arthroscopy has become the preferred technique for the treatment of acetabular labrum injury. Labral repair is still the first choice, and labral reconstruction is used when acetabular labrum injury cannot be repaired.
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Affiliation(s)
- Jiangang Cao
- Department of Sports Injury and Arthroscopy, Tianjin Hospital, Tianjin, 300222, P.R.China
| | - Desheng Chen
- Department of Sports Injury and Arthroscopy, Tianjin Hospital, Tianjin, 300222, P.R.China
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Mehta MP, Hoffer-Hawlik MA, O'Connor M, Lynch TS. Immediate Versus Delayed Hip Arthroscopy for Femoroacetabular Impingement: An Expected Value Decision Analysis. J Am Acad Orthop Surg Glob Res Rev 2020; 4:e20.00206. [PMID: 33986209 PMCID: PMC7725252 DOI: 10.5435/jaaosglobal-d-20-00206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/21/2020] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Hip arthroscopy is an increasingly used surgical procedure for both intra- and extra-articular hip pathologies, including femoroacetabular impingement (FAI). Although the arthroscopic approach is known to be preferable to open, the optimal timing of such intervention is unclear. The purpose of this study was to carry out an expected value decision analysis of immediate versus delayed hip arthroscopy for FAI. Its hypothesis is immediate hip arthroscopy is the preferable treatment option. METHODS An expected value decision analysis was implemented to systematize the decision-making process between immediate and delayed hip arthroscopies. A decision tree was created with options for immediate and delayed surgeries with utilities characterizing each state obtained from surveying 70 patients. Fold-back analysis was then carried out, calculating expected values by multiplying the utility of each health outcome by the probability of that outcome. Corresponding expected values were then summed to "fold back" the decision tree one layer at a time. This was repeated until overall expected values (0 to 100) for immediate and delayed hip arthroscopies resulted with the higher value indicating the preferable option. RESULTS Fold-back analysis demonstrated that immediate hip arthroscopy is the preferred treatment for FAI over delayed with expected values of 78.27 and 72.63, respectively. Restoration of good function after hip arthroscopy was the most notable contributor to this difference. Immediate hip arthroscopy remained superior even as vast adjustments to preoperative physical function were made in one-way sensitivity analysis. Complications of hip arthroscopy leading to total hip arthroplasty were the least notable contributors to overall expected values. DISCUSSION This study confirms that immediate surgery is the preferred option when using decision-making analysis combining patient-reported utilities of health outcomes and the probabilities of those outcomes from the literature. This is consistent across a range of estimates of poor function in both the delayed and immediate surgery arms.
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Affiliation(s)
- Manish P Mehta
- From the Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY
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Yacovelli S, Parvizi J. Return to Sports After Joint Preservation Hip Surgery. Orthop Clin North Am 2020; 51:427-439. [PMID: 32950212 DOI: 10.1016/j.ocl.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Femoroacetabular impingement results from a mismatch of congruency between the femoral head and the acetabulum. This condition is most common among young, active patients and may lead to pain, decreased quality of life, and inability to participate in athletics. Hip preservation surgery is widely performed is used as a definitive treatment option in athletes at all levels of competition. Athletes have reported high rates of return to play and satisfaction and expect rehabilitation to require approximately 4 to 6 months. This article provides an overview of femoroacetabular impingement, including diagnosis and treatment, with focus on athletes and return to play.
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Affiliation(s)
- Steven Yacovelli
- The Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Javad Parvizi
- The Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA.
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Hassebrock JD, Makovicka JL, Chhabra A, Anastasi MB, Menzer HM, Wilcox JG, Economopoulos KJ. Hip Arthroscopy in the High-Level Athlete: Does Capsular Closure Make a Difference? Am J Sports Med 2020; 48:2465-2470. [PMID: 32667821 DOI: 10.1177/0363546520936255] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Hip arthroscopy has been shown to be effective in athletes who have femoral acetabular impingement and labral tearing. The effect of complete capsular closure versus nonclosure on return to play is unknown. HYPOTHESIS Complete capsular closure after hip arthroscopy would lead to a higher rate and faster return to sports in high-level athletes. STUDY DESIGN Cohort study; Level of evidence, 3. METHODS A nonrandomized retrospective review was performed of high school, collegiate, and professional athletes undergoing hip arthroscopy by a single high-volume hip arthroscopic surgeon. Athletes were divided into those undergoing complete capsular closure (CC group) and non-capsular closure (NC group) after hip arthroscopy. Rate and time to return to play were determined between the 2 groups. Patient-reported outcomes including modified Harris Hip Score (mHHS), Hip Outcome Score Activities of Daily Living (HOS-ADL), and Hip Outcome Score Sport-Specific Subscale (HOS-SSS) were obtained at a minimum of 2 years. RESULTS A total of 111 athletes with a minimum 2-year follow-up were included in the study. There were 62 in the CC group and 49 in the NC group. A higher percentage of athletes in the CC group returned to play compared with that in the NC group (90.3% vs 75.5%, respectively; P = .03). The CC group returned to play at a mean ± SD of 4.7 ± 1.9 months compared with 5.8 ± 2.6 months in the NC group (P < .001). Patients in the CC group met the minimal clinically important difference for the mHHS, HOS-ADL, and HOS-SSS patient-reported outcomes at higher percentages: mHHS, 98.3% vs 87.7% for CC vs NC, respectively (P = .02); HOS-ADL, 98.3% vs 87.7% (P = .02); and HOS-SSS, 96.7% vs 89.7% (P = .13). The difference between groups was statistically significant for mHHS and HOS-ADL. CONCLUSION Complete capsular closure after hip arthroscopy was associated with faster return to play and a higher rate of return compared with that of nonclosure of the capsule in this sample population of high-level athletes. At a minimum 2-year follow-up, complete capsular closure was associated with significantly higher patient-reported outcomes compared with those of nonclosure in athletes who underwent hip arthroscopy.
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Affiliation(s)
| | | | - Anikar Chhabra
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona, USA
| | | | - Heather M Menzer
- Department of Orthopaedics, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Justin G Wilcox
- Department of Orthopedics, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Moley PJ, Tatka J, Singh JR. Running with Femoral Acetabular Impingement: Operative Vs Nonoperative Treatment. PM R 2020; 12:817-822. [PMID: 32535998 DOI: 10.1002/pmrj.12438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 06/11/2020] [Indexed: 11/08/2022]
Abstract
A 31-year-old female lawyer presents with right hip pain starting approximately 3 years ago and worsening over the past 2 to 3 months. She is an avid runner, running 20 to 30 miles weekly, and noticed that her pain started after a running program training for the marathon. Her pain is primarily over the lateral aspect of her hip with some radiation into the groin. The pain is made worse with impact exercises such as running and made better with walking and cycling. She has done physical therapy for the past 3 months without any significant improvement. She has not had any injections or taken anti-inflammatories because of a history of gastric ulcer disease. On physical examination she has mild tenderness over her right greater trochanter and her range of motion tests are full in terms of flexion, internal rotation, and external rotation. She has a positive FADIR (flexion-adduction-internal rotation) impingement that causes both groin and lateral hip pain. Radiograph of the right hip revealed preservation of the joint space and an anterior cam lesion with reduced offset at the femoral head neck junction. Magnetic resonance imaging (MRI) of the right hip revealed a tear at the anterior superior labrum at the 1 to 2 o'clock position along with subjacent bone marrow edema in the femoral head that is likely reactive. Computed tomography (CT) scan of the right hip confirmed a combined cam and pincer type femoral acetabular impingement of the right hip with overcoverage of the femoral head. There was 15° of femoral anteversion and the coronal lateral center of edge angle (LCEA) is 34°. Dr. Peter Moley argues that a focused rehabilitation program to restore strength and motor control of the deep hip stabilizers will provide optimal functional recovery. Dr. Jakub Tatka argues that right hip arthroscopy with labral repair and possible osteochondralplasty are indicated in order to prevent early hip arthritis and prevent long-term sequela of femoral acetabular impingement.
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Affiliation(s)
| | - Jakub Tatka
- Department of Orthopedic Surgery, Columbia University, New York, NY, USA
| | - Jaspal Ricky Singh
- Weill Cornell Medicine, Department of Rehabilitation Medicine, Weill Cornell Center for Comprehensive Spine Care, New York, NY, USA
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Editorial Commentary: The Wild, Wild West of Hip Arthroscopy-When to Pull the Trigger? Arthroscopy 2020; 36:1030-1032. [PMID: 32247402 DOI: 10.1016/j.arthro.2020.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 01/29/2020] [Accepted: 02/04/2020] [Indexed: 02/02/2023]
Abstract
In our continued effort to refine the treatment algorithm of femoroacetabular impingement syndrome, duration of symptoms before surgery is receiving considerable attention by researchers. A (somewhat) negative linear correlation is being elucidated between outcomes and extent of damage at time of arthroscopy. Knowing this, it may be prudent in certain patient populations to recommend surgery earlier in the disease process in hopes of minimizing the amount of damage to the joint to delay or avoid the onset of arthritis.
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Arakgi ME, Han F, Degen R. Role of Arthroscopy for Hip Osteoarthritis with Impingement. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00141-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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