Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study

PURPOSE

To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater.

METHODS

An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%.

RESULTS

Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration.

CONCLUSIONS

There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy.

LEVEL OF EVIDENCE

Level V, expert opinion.

PREHAB FAI- Prehabilitation for patients undergoing arthroscopic hip surgery for Femoroacetabular Impingement Syndrome -Protocol for an assessor blinded randomised controlled feasibility study

BACKGROUND

The past decade has seen an exponential growth of minimally invasive surgical procedures. Procedures such as hip arthroscopy have rapidly grown and become the standard of care for patients with Femoroacetabular Impingement Syndrome (FAIS). Although, the results of such procedures are encouraging, a large proportion of patients do not achieve optimal outcomes due to chronicity and deconditioning as a result of delay in diagnosis and increased waiting times amongst other factors. In a recent systematic review and meta-analysis of randomised control trials, moderate certainty evidence supported prehabilitation over standard care in optimising several domains including muscle strength, pain and health related quality of life in patients undergoing orthopaedic surgical interventions. However, the role of prehabilitation in patients with FAI syndrome undergoing hip arthroscopy has received little attention.

AIM

To evaluate the feasibility, suitability, acceptability and safety of a prehabilitation programme for FAI to inform a future definitive randomised control trial to assess effectiveness.

METHODS

A systematically developed prehabilitation intervention based on a literature review and international consensus will be utilised in this study. A mixed methodology encompassing a two-arm randomised parallel study alongside an embedded qualitative component will be used to answer the study objectives. Patients will be recruited from a tertiary referral NHS centre for young adult hip pathology in the UK. Patient reported outcomes such as iHOT-12, Brief Pain Inventory Scale (Short form), Hospital Anxiety and Depression Scale and Patient Global Impression of Change score will be obtained alongside objective measurements such as Muscle Strength and Star Excursion Balance Test at various time points. Outcome measures will be obtained at baseline (prior to prehabilitation intervention), after prehabilitation before surgery, and at 6 weeks+/- 4 weeks and 6 months +/- 4 weeks (planned primary endpoint for definitive RCT) postoperatively when participants attend the research site for clinical care and remotely at 12 months +/- 4 weeks postoperatively. Mean change and 95% CI, and effect size of outcome measures will be used to determine the sample size for a future RCT. For the qualitative component, in depth face-to-face semi-structured interviews with physiotherapists and focus groups with participants will be conducted to assess the feasibility, suitability, and acceptability of the prehabilitation intervention using a predetermined success criteria. All qualitative data will be recorded, transcribed verbatim and thematically analysed.

DISCUSSION

This study will be first of its kind to evaluate a systematically developed prehabilitation intervention for patients with FAIS undergoing hip arthroscopy. This study will provide important preliminary data to inform feasibility of a definitive RCT in the future to evaluate effectiveness of a prehabilitation intervention.

TRIAL REGISTRATION

ISRCTN 15371248, 09/03/2023.

TRIAL PROTOCOL

Version 2.3, 26th June 2023.

Editorial Commentary: Artificial Intelligence Analysis of Biomedical, Large, Clinical Registry Data Using Machine Learning Requires Tens of Thousands of Subjects and a Focus on Substantial Clinical Benefit: Minimal Clinically Important Difference Is too Low a Bar

As the field of arthroscopic hip preservation surgery grows, large high-quality registries represent a foundational study design for establishing whether hip arthroscopy is effective for patients with femoroacetabular impingement syndrome (FAIS). Original research publications from experienced high-volume surgeons tell us "Can it work". A registry tells us "Does it work?". The ability of preservation to truly preserve the joint, delay the arthritis process, and reduce the risk of arthroplasty requires long-term follow-up. A geographic registry can follow this. The registry represents the "real world", a heterogeneous set of variables pertaining to the doctor, patient, intervention, and outcome. The vast array of factors that can be analyzed before, during, and after surgery makes machine learning an ideal technique for analysis of large quantities of data. A global hip preservation surgery registry is a desirable and achievable goal. In order to optimally predict outcome of hip arthroscopy, given the known large number of patient- and hip-specific factors that influence outcomes, a deep learning model with tens of thousands of subjects for this medium-scale task would be needed. Measures of clinical relevance need to include more than just MCID (minimal clinically important difference), which is the lowest bar minimal threshold. Patient expectations often far exceed MCID-requiring other metrics like SCB (substantial clinical benefit), PASS (patient acceptable symptom state), and MOI (maximal outcome improvement). Registries should include validated, reliable, and responsive patient-reported outcome scores (e.g., International Hip Outcome Tool [iHOT-12]) with measures of clinical relevance and expectations assessed routinely. The United Kingdom's NAHR (Non-Arthroplasty Hip Registry) and Denmark's DHAR (Danish Hip Arthroscopy Registry) are the two largest geography-based registries in current hip preservation research both with 11 years of patient enrollment.

Current concepts in the diagnosis and management of Os Acetabuli

PURPOSE

The aim of this review is to appraise the current evidence on the epidemiology, pathophysiology, diagnosis and management of os acetabuli.

METHODS

A scoping review was conducted according to the Joanna Briggs Institute guidelines. A systematic search was performed on Medline (PubMed), Embase and Cochrane Library. Inclusion criteria comprised observational and interventional studies and review articles published in the English language that focused on patients with os acetabuli according to the PRISMA extension of scoping reviews checklist using the terms 'Os Acetabuli' or 'os acetabula' or 'acetabular ossicles'. A narrative synthesis of results was undertaken, and the included articles were divided into (i) definition, (ii) aetiology, (iii) diagnosis and imaging and (iv) management of os acetabuli.

RESULTS

107 articles were screened, with 22 meeting the eligibility criteria. A total of 8836 patients were considered, of which 604 had os acetabuli. The mean age was 32.8 years. The prevalence of os acetabuli ranged from 3.4 to 7.7%, with a higher prevalence in males compared to females. True os acetabuli was defined as an unfused secondary ossification centre along the acetabular rim. The aetiology of os acetabuli is thought to be secondary to acetabular dysplasia and/or femoroacetabular impingement. Standard of care for management of symptomatic os acetabuli is considered to be arthroscopic excision unless the excision results in acetabular undercoverage and/or instability, in which case, fixation is recommended.

CONCLUSIONS

Successful management of os acetabuli depends on understanding the pathology and treating the underlying cause rather than treating the os acetabuli in isolation. Future work needs to focus on establishing clear diagnostic criteria, consensus on definition and an evidence-based treatment algorithm.

No Differences in Clinical Outcomes Between Hip Arthroscopy With Versus Without Capsular Closure in Patients With Cam- or Mixed-Type Femoroacetabular Impingement: A Randomized Controlled Trial

PURPOSE

To compare 2-year clinical outcomes of primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in patients with cam- or mixed-type femoroacetabular impingement (FAI).

METHODS

Patients with cam- or mixed-type FAI undergoing primary hip arthroscopy with interportal capsulotomy were prospectively enrolled in this randomized controlled trial (RCT) and allocated into either capsular closure or no capsular closure groups. Patients were blinded to group allocation. Clinical outcomes were assessed preoperatively and at 2-year follow-up using the 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and 6 subsections of the Copenhagen Hip and Groin Outcome Score (HAGOS). Complications and reoperations were noted.

RESULTS

Eighty-four patients (100 hips) were enrolled, 49 hips in the capsular closure group and 51 in the no capsular closure group, with no significant differences in age (28.5 ± 7.5 vs 30.4 ± 8.4, P = .261), body mass index (23.5 ± 3.0 vs 23.4 ± 1.9, P = .665), and sex distribution (female: 10.2% vs 13.7%, P = .760). Four patients were lost to follow-up (2.0% vs 5.9%, P = .618) and 6 had reoperations (6.1% vs 5.9%, P = 1.000), which left 45 hips per group for clinical assessment. There were no significant differences between groups in the net change of iHOT-12 (28.3 ± 19.6 vs 32.5 ± 22.7, P = .388), mHHS (7.6 ± 13.1 vs 7.5 ± 10.2, P = .954), and subsections of HAGOS (P > .05). Complication rates were also similar between groups (P > .05).

CONCLUSIONS

The present RCT compared primary hip arthroscopy with versus without capsular closure after interportal capsulotomy in a male-dominated, non-dysplastic, non-arthritic cohort with cam- or mixed-type FAI and found no significant differences in patient-reported clinical outcomes, complication rates, or reoperation rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

Long-term Follow-up After Endoscopic Gluteal Repair Plus Hip Arthroscopy Shows Durable Results Using Validated Patient-Reported Outcome Scores That Largely Exceed the Minimal Clinically Important Difference and Patient Acceptable Symptom State

Gluteus medius and minimus tendon pathology is a common cause of lateral hip pain. In patients that are dissatisfied with their hip condition following non-surgical treatment, gluteal repair has demonstrated excellent short-, mid-, and now recently, long-term subjective patient-reported and objective clinician-measured outcomes. In patients with peritrochanteric hip pain, the proportion of their overall hip pain may be influenced by the hip joint due to conditions like Femoroacetabular Impingement Syndrome (FAIS), acetabular dysplasia, labral tears, and arthritis. Thus, surgical decision-making must include consideration of also addressing the joint at the same time as the gluteal repair. This is sometimes challenging due to the high frequency of observing labral injuries and cam/pincer/dysplasia morphology in patients without symptoms due to the "radiographic abnormalities". Labral pathology is also more prevalent in older patients, which happen to also be those individuals also presenting with symptomatic gluteal tendon pain. Both open and endoscopic approaches to the gluteal tendons have advantages and disadvantages without significant outcomes differences in short- or mid-term. Long-term clinical follow-up of patients treated with endoscopic gluteal repair with or without concomitant hip arthroscopy should be included in large national and international prospective registries using validated, reliable, and responsive patient-reported outcome scores, with clinical importance assessed using the minimal clinically important difference (MCID), patient acceptable symptom state (PASS), substantial clinical benefit (SCB), and maximal outcome improvement (MOI).

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Methods

A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected.

Results

A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015).

Conclusion

There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.