Femoroacetabular impingement surgery leads to early pain relief but minimal functional gains past 6 months: experience from the FIRST trial

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review

Purpose

To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy.

Methods

PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05.

Results

Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001).

Conclusions

This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population.

Level of Evidence

Level II, systematic review of level I and II evidence.

Femoroacetabular impingement - What the rheumatologist needs to know

Femoroacetabular impingement (FAI) syndrome is a common cause of hip and groin pain in young individuals. FAI syndrome is a triad of signs, symptoms, and imaging findings. Necessary but not sufficient for the diagnosis of FAI syndrome is the presence of cam and/or pincer morphology of the hip. However, pathological thresholds for cam and pincer morphologies are not well-established. Management of FAI syndrome is typically through either physiotherapist-led therapy or surgical intervention. Physiotherapist-led management involves exercises aimed to optimise movement patterns of the hip and pelvis to prevent impingement from occurring, activity modification and analgesia, whereas surgical management involves arthroscopic resection of the cam/pincer morphology and treatment of concomitant soft tissue pathologies such as labral tears, cartilage lesions or ligamentum teres tears. Careful consideration of intervention is required given that FAI syndrome may predispose those affected to developing future osteoarthritis of the hip. In most clinical trials, hip arthroscopy has been found to provide greater improvement in patient-reported outcomes in the short-term compared to physiotherapy, however it is unknown whether this is sustained in the long-term or affects the future development of hip osteoarthritis.

The Influence of Compensatory Pelvic Tilt on Patient-reported Outcome Measurements in FAI Patients Who Received Arthroscopic Treatment

OBJECTIVE

Pelvic compensation is common in femoroacetabular impingement (FAI) patients to reduce symptoms and increase range of motion. However, little attention was given to the postoperative clinical effect of pelvic compensation. Therefore, this study aims to compare the outcomes between pelvic compensation and normal pelvic position in femoroacetabular impingement (FAI) patients after hip arthroscopy.

METHODS

The retrospective study was conducted from January 2019 to June 2022, recruited consecutive patients who were diagnosed with FAI and received subsequent arthroscopic treatment. All patients completed an X-ray in the anterior-posterior standing position before and 4 weeks after surgery. Patients with pelvic compensation were compared with those who did not. Functional outcomes included hip disability and osteoarthritis outcome score (HOOS), modified Harris (mHHS) score, and lower-extremity activity scale (LEAS). Secondary outcomes included the EuroQol Five Dimensions Questionnaire (EQ-5D) and patient satisfaction. The intraclass correlation coefficient (ICC) was used to analyze interobserver and intraobserver reliability.

RESULTS

Ninety patients with a mean age of 39.40 years were included in the study. No significant compensation changes were noted within groups after the elimination of impingement. The functional scores showed no significant difference between groups (p(HOOS) = 0.352, p(mHHS) = 0.183, p(LEAS) = 0.865). The EQ-5D revealed statistically better performance in usual activities in the compensatory group (p = 0.044). There are no significant between-group differences in patients' satisfaction evaluations.

CONCLUSION

As assessed by Patient-Reported Outcome Measures (PROMs), patients with compensatory pelvic tilt demonstrated similar clinical outcomes without extra adverse events to patients with normal pelvic positioning in short-term follow-ups. Furthermore, compensatory pelvic tilt did not significantly enhance the range of motion or functional outcome at short-term follow-ups.

Editorial Commentary: Hip Arthroscopy Outcomes in Older Patients Can Equal Outcomes in Younger Patients With Proper Surgical Indications

Hip arthroscopy patients often present with clinical features that help broadly categorize them as the younger patient with femoroacetabular impingement, the microinstability- or instability-related patient, those patients with predominant peripheral compartment disease, and the older patient with femoroacetabular impingement plus peripheral compartment disease. Outcomes in older patients can equal outcomes in younger patients with proper surgical indications. Specifically, older hip arthroscopy patients do well in the absence of degenerative articular cartilage changes. Although some studies have suggested a potential for greater conversion rate to hip arthroplasty in an older age group, with proper patient selection, hip arthroscopy may lead to durable and significant improvements.

Do the outcomes of hip arthroscopy for femoroacetabular impingement change over time?

BACKGROUND

The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up.

HYPOTHESIS

We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up.

PATIENTS AND METHODS

Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis.

RESULTS

Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25-37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75-91.25) and 85.8 (IQR 66.7-96.7) respectively (p<0.001). Medium-term survivorship was 91.2%. Survivorship following labral repair was 94.2%, and 81.3% following labral debridement (p=0.09).

DISCUSSION

Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up.

LEVEL OF EVIDENCE

IV, Case series.

Osteochondroplasty Benefits the Pragmatic Patient With Femoroacetabular Impingement: Analysis From the Embedded Prospective Cohort of the Femoroacetabular Impingement RandomiSed Controlled Trial (FIRST)

PURPOSE

To determine whether arthroscopic osteochondroplasty demonstrated effectiveness in a pragmatic femoroacetabular impingement patient population embedded within FIRST (the Femoroacetabular Impingement RandomiSed controlled Trial).

METHODS

All cohort patients were not randomized and were followed prospectively with a follow-up assessment protocol identical to that in FIRST. The primary outcome was hip pain using a 100-point visual analog scale. Secondary outcomes included hip function (Hip Outcome Score, International Hip Outcome Tool-12), health utility (EuroQol 5 Dimensions), and health-related quality of life (Short Form-12) at 12 months, as well as operatively and nonoperatively treated hip complications at 24 months. We performed multivariable regressions to compare these outcomes between 3 groups of patients: (1) those randomized to lavage in FIRST, (2) those randomized to osteochondroplasty in FIRST, and (3) those who received osteochondroplasty as part of the cohort study.

RESULTS

All groups had improvements across all questionnaire outcomes from baseline to 12 months, with no significant differences. There were significantly more reoperations in the lavage trial group compared with those in the embedded cohort (adjusted odds ratio [aOR] 3.08; 95% confidence interval [CI] 1.23-7.73; P = .016). There were significantly more nonoperatively treated hip complications in the lavage trial group and in the osteochondroplasty trial group when compared with those in the embedded cohort (aOR 3.81; 95% CI 1.19-12.17; P = .024 and aOR 4.55; 95% CI 1.43-14.42; P = .010, respectively).

CONCLUSIONS

Hip arthroscopic osteochondroplasty and lavage led to improvement in hip pain, function, and health-related quality of life at 12 months across both randomized controlled trial (RCT) and cohort patients. The pragmatic cohort receiving osteochondroplasty had (1) significantly fewer complications than RCT patients, (2) significantly less reoperations than RCT patients randomized to arthroscopic lavage, and (3) fewer, although nonsignificant, reoperations than RCT osteochondroplasty patients.

LEVEL OF EVIDENCE

II, therapeutic.

Bilateral hip arthroscopy for treating femoroacetabular impingement: a systematic review

PURPOSE

Femoroacetabular impingement (FAI) is a hip disorder which can often present bilaterally. The purpose of this systematic review was to explore the current practices for bilateral hip arthroscopy in treating FAI as they relate to outcomes and complications.

METHODS

This review has been conducted according to the guidelines of Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). The electronic databases PubMed, MEDLINE, EMBASE, and CENTRAL (Cochrane Central Register of Controlled Trials) were searched from data inception to October 18th, 2020. The Methodological Index for Non-randomized Studies (MINORS) was used to assess study quality. Data are presented descriptively.

RESULTS

Overall, 19 studies were identified, comprising 957 patients (48.6% male) with a mean age of 27.9 ± 7.1 years and a mean follow-up of 31.7 ± 20.8 months. The majority of patients were treated with a staged bilateral hip arthroscopy (78.5%) with a mean duration between surgeries of 7.1 ± 4.0 months. Significant preoperative-to-postoperative improvements for clinical outcomes such as pain, hip function, and health-related daily living as well as radiographic outcomes were reported in six studies for staged procedures (p < 0.05) and three studies for simultaneous procedures (p < 0.02). Significant improvements in patient-reported outcomes (e.g., HOS-ADL, Pain, HOS-SS, mHHS, and NAHS) were found in favor of those undergoing a shorter delay between surgeries in three studies (i.e., < 3, 10 or 17 months) (p < 0.05) compared to those who had delayed surgeries (i.e., > 3, 10, or 17 months). The overall complication rate was 10.1% (97/957).

CONCLUSIONS

Bilateral surgery for FAI yields improved outcomes postoperatively and complication rates similar to unilateral surgery. The overall complication rate was 10.1% with the most common complication being revision surgery. Staged bilateral surgery is more commonly performed than simultaneous surgery. Clinicians should consider preoperative imaging, clinical history, and patient values when deciding between staged and simultaneous procedures for bilateral FAI surgery. Future studies are required to determine the optimal indications for simultaneous versus staged procedures, as well as the ideal timing between surgeries for the latter.

LEVEL OF EVIDENCE

Level IV.

Patients Require Less Time to Complete Preoperative Patient-Reported Outcomes Measurement Information System (PROMIS) Than Legacy Patient-Reported Outcome Measures

Purpose

To analyze time to completion of preoperative legacy patient-reported outcomes (PROs) and more recent computer adaptive Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires in patients with symptomatic femoroacetabular impingement syndrome undergoing primary hip arthroscopy.

Methods

A retrospective analysis was conducted on patients undergoing hip arthroscopy by a single fellowship-trained hip arthroscopist. Inclusion criteria were patients undergoing primary arthroscopic hip surgery and completion of at least 1 legacy PRO or PROMIS questionnaire at the preoperative time point. Exclusion criteria were history of contralateral or ipsilateral hip surgery, non-English-speaking patients, patients who completed PROs by phone or by paper form, and patients who did not complete preoperative PROs. Legacy PROs included modified Harris Hip Score (mHHS), Hip Outcome Score (HOS), International Hip Outcome Tool (iHOT-12), and Hip Pain Visual Analog Scale (VAS-Pain). PROMIS PROs included Physical Function (PROMIS-PF), Pain Interference (PROMIS-PI), and Depression (PROMIS-D). Only preoperative PROs were included in the analysis. Completion time was calculated using the questionnaire start and stop time reported by the survey collecting software. The median and interquartile range of each PRO were reported for analysis of central tendency and statistical dispersion, respectively.

Results

A total of 1,901 patients and 269 patients were included in the legacy and PROMIS groups, respectively. The median time required for completion of each PRO in (minutes: seconds) format was as follows: mHHS (1:29), HOS (3:58), iHOT (2:11), VAS-Pain (0:32), PROMIS-PF (0:46), PROMIS-PI (0:37), and PROMIS-D (0:43). The interquartile range of the middle 50% of respondents was as follows; mHHS (0:58), HOS (2:46), iHOT (1:22), VAS-Pain (0:28), PROMIS-PI (0:19), PROMIS-D (0:29), and PROMIS-PF (0:20).

Conclusions

This study supports that preoperative PROMIS forms require less time to complete than preoperative legacy PROs and are not significantly influenced by age, race, or workers compensation status.

Level of Evidence

Level IV, case series.

Persistent post-operative opioid use following hip arthroscopy is common and is associated with pre-operative opioid use and age

PURPOSE

Hip arthroscopy utilization continues to increase worldwide. Post-operative pain management is essential to allow appropriate rehabilitation. While multimodal analgesic protocols have been described, consensus agreement is lacking and opioid analgesia remains a mainstay of treatment. Unfortunately, the risk of persistent opioid use among opioid-naïve and non-naïve patients following hip arthroscopy remains unclear. Therefore, the purpose of this study was to identify rates of persistent post-operative opioid use, as well as to identify factors associated with persistent use.

METHODS

A retrospective cohort study was conducted using linked administrative data from Ontario, Canada. Participants were adults who underwent hip arthroscopy between 2013 and 2018. Patients < 18 or > 60 years of age as well as those who had undergone prior hip arthroscopy were excluded. The primary exposure was whether patients had filled ≥ 2 opioid prescriptions within 1 year prior to their hip arthroscopy to define the opioid naïve and non-naïve populations. The primary outcome was persistent opioid use, defined as 2 + prescriptions filled between 9 and 15 months post-op. A regression analysis was performed to identify factors associated with persistent opioid usage.

RESULTS

Of the 1909 patients, 1525 (79.9%) were opioid-naïve, while 384 (20.1%) had a prior history of opioid use within 1 year of surgery. 224 patients (11.7%) demonstrated persistent opioid use, with ≥ 2 prescriptions filled between 9 and 15 months post-op. Of those, 42 (18.8%) cases were among opioid-naïve patients, while the remaining 182 (81.2%) were among non-naïve patients. The risk of persistent post-operative use was significantly higher in those with prior opioid use (OR 31.95, 95% CI 22.15-46.09; p < 0.0001). Regression analysis confirmed that pre-operative opioid use (OR 23.79, 95% CI 17.06-33.17; p < 0.0001) and older age (OR 1.04, 95% CI 1.02-1.05, p < 0.0001) were associated with increased risk of persistent post-operative opioid use.

CONCLUSION

Following hip arthroscopy, persistent opioid use is common. New persistent use was identified in 2.7% of opioid-naïve patients, compared with continued use in 47.4% of non-naïve patients. Pre-operative opioid use and older age were associated with the greater risk of persistent post-operative opioid use.

LEVEL OF EVIDENCE

Level III.