A comparison of 6-month outcomes between periacetabular osteotomy with concomitant hip arthroscopy to isolated hip arthroscopy for femoroacetabular impingement

Patients Undergoing Hip Arthroscopy With Concomitant Periacetabular Osteotomy Demonstrate Clinically Meaningful Improvement at 2 Years Using the Patient-Reported Outcome Measurement Information System and International Hip Outcome Tool 12

PURPOSE

To report the minimal clinically important difference (MCID) and substantial clinical benefit (SCB) values using the Patient-Reported Outcome Measurement Information System (PROMIS) and International Hip Outcome Tool 12 (iHOT-12) in patients undergoing hip arthroscopy (HA) with concomitant periacetabular osteotomy (PAO), HA + PAO for acetabular dysplasia, and intra-articular pathology with a minimum 2-year follow-up.

METHODS

Data from patients who underwent HA + PAO were prospectively collected and retrospectively analyzed. Inclusion criteria consisted of patients who had a diagnosis of hip dysplasia or hip instability and had a minimum 2-year patient-reported outcome measure follow-up. Data were collected electronically preoperatively and postoperatively at 6 months, 1 year, and 2 years. Outcome measures analyzed were the iHOT-12 and PROMIS computer adaptive tests: Physical Function (PF), Pain Interference (PI), and Global Physical Health (GPH). MCID and SCB were calculated for these measures.

RESULTS

In total, 106 patients were included in the study with an average age of 23.5 ± 6.6 years, an average body mass index of 24.3, and the majority being female (94%). The values for MCID were calculated to be 40.9, 40.7, 60.2, and 43.5, and the percentage achieving MCID at 2 years was 82.6%, 82.9%, 79.6%, and 80.1% for the iHOT-12, PROMIS-PF, PROMIS-PI, and PROMIS-GPH respectively. The 1-year and 2-year SCB scores for ≥80% satisfaction and percent achieving were as follows, respectively: iHOT-12, 71.8 (60.3%), 61.9 (65.1%); PROMIS-PF, 47.1 (64.2%), 47.2 (71.7%); PROMIS-PI, 50.6 (48.1%), 52.3 (49.1%); and PROMIS-GPH, 49.3 (54.7%), 49.3 (55.7%). The 1-year and 2-year SCB scores for 100% satisfaction and percent achieving were as follows, respectively: iHOT-12, 80.2 (44.3%), 81.3 (47.2%); PROMIS-PF, 50.7 (46.2%), 50.3 (56.6%); PROMIS-PI, 52.4 (34.9%), 52.4 (49.1%); and PROMIS-GPH, 52.5 (36.8%), 49.3 (55.7%).

CONCLUSIONS

This study reports values for MCID and SCB for PROMIS and iHOT-12 at a 2-year follow-up in patients undergoing HA + PAO for hip dysplasia or instability. The percentage of patients achieving MCID ranged from 79.6% to 82.9% at the 2-year follow-up. In addition, the percentage of patients achieving SCB at the 2-year follow-up for ≥80% satisfaction ranged from 49.1% to 71.2%, and the percentage for 100% satisfaction ranged from 49.1% to 56.6%.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Patient-Reported Outcomes Measurement Information System Is Not as Responsive as Legacy Scores in Detecting Patient Outcomes in Hip Preservation: A Systematic Review

PURPOSE

To evaluate publication trends of Patient-Reported Outcomes Measurement Information System (PROMIS) in hip preservation literature, assess the usage of PROMIS as an outcome measure, and evaluate correlations of all available published PROMIS domains with legacy patient-reported outcomes (PROs).

METHODS

The PubMed, Scopus, Cochrane Central Register of Controlled Trials, and Google Scholar databases were queried for articles evaluating PROMIS scores among hip preservation populations. Inclusion criteria consisted of studies with Level IV evidence or above (per the Sackett et al. levels of evidence), such as case series and cohort studies, reporting on perioperative use of hip PROMIS scores. Exclusion criteria consisted of arthroplasty and trauma studies. Patient demographics, PROMIS usage, and PROMIS Pearson or Spearman correlation coefficients to historic PROs were recorded for each study.

RESULTS

Fifteen articles published between 2017 and 2021 were included in the analysis, with the majority (75%) published between 2020 and 2021. Studies assessing postoperative outcomes had follow-up periods ranging from 6 months to 5 years. The most common PROMIS domain reported was Physical Function (PF), and there was varying usage of other domains including Pain Intensity, Anxiety, and Depression. PROMIS validity was most often assessed in comparison to the modified Harris Hip Score (mHHS) by calculating the Pearson coefficient, which assumes normal data distribution, or Spearman coefficient, which is rank-based and does not require normal data distribution. Studies comparing PROMIS-PF with mHHS reported Pearson coefficients ranging from 0.49 to 0.72 and Spearman coefficients ranging from 0.67 to 0.71.

CONCLUSIONS

There has been a chronologic increase in PROMIS usage in hip preservation literature. PROMIS demonstrates moderate-to-strong correlations with legacy PROs, but there is substantial heterogeneity in follow-up periods, PROMIS domains used, and statistical methodology. The current data show that PROMIS is not as responsive as historically used, validated PROs in quantitatively assessing function and pain in hip preservation patients.

CLINICAL RELEVANCE

Surgeons using PROMIS solely should be aware that the score may not be as responsive as legacy PROs in closely assessing improvements or deterioration in patient performance after hip preservation surgery. Rather than being used alone, PROMIS may be useful as a replacement for a group of legacy PROs. Thus, when used alongside select legacy PROs, overall questionnaire burden can be reduced while maintaining a high level of accuracy in assessing health status.

Rehabilitation Guidelines for Use Following a Periacetabular Osteotomy (PAO): A North American Based Delphi Consensus

Background

Treatment of acetabular dysplasia with a periacetabular osteotomy (PAO) has been shown to improve long term outcomes and is considered the gold standard in the setting of symptomatic hip dysplasia in patients younger than 35 years of age. Post-operative rehabilitation following a PAO plays an important role in helping patients return to their prior level of function and reduce the impact of strength deficits that may persist. Currently, there is a paucity of research supporting post-operative rehabilitation guidelines. The purpose of this study is to present expert-driven rehabilitation guidelines to reduce practice variation following a PAO.

Methods

A panel of 16 physiotherapists from across the United States and Canada who were identified as experts in PAO rehabilitation by high-volume hip preservation surgeons participated in this Delphi study. Panelists were presented with 11 questions pertaining to rehabilitation guidelines following a PAO. Three iterative survey rounds were presented to the panelists based on responses to these questions. This three-step Delphi method was utilized to establish consensus on post-operative rehabilitation guidelines following a PAO.

Results

Total (100%) participation was achieved for all three survey rounds. Consensus (>75%) was reached for 11/11 questions pertaining to the following areas: 1) weight-bearing and range of motion (ROM) precautions, 2) therapeutic exercise prescription including neuromuscular control, cardiovascular exercise, and flexibility, and 3) objective measures for return to straight line running and return to full participation in sports.

Conclusion

This Delphi study established expert-driven rehabilitation guidelines for use following a PAO. The standardization of rehabilitative care following PAO is essential for achieving optimal outcomes despite other factors such as geographical location and socioeconomic status. Further research on patient-reported outcomes is necessary to confirm successful rehabilitation following the guidelines outlined in this study.

A higher proportion of patients may reach the MCID with capsular closure in patients undergoing arthroscopic surgery for femoroacetabular impingement: a systematic review and meta-analysis

PURPOSE

The purpose of this review is to provide a summary of the techniques and outcomes of various capsular management strategies in patients undergoing hip arthroscopy for femoroacetabular impingement (FAI). The information this review provides on capsular management strategies will provide surgeons with operative guidance and decision-making when managing patients with FAI lesions arthroscopically.

METHODS

Three databases MEDLINE, EMBASE, and PubMed were searched from database inception to November 2nd 2021, for literature addressing capsular management of patients undergoing hip arthroscopy for FAI. All level I-IV data on capsular management strategy as well as postoperative functional outcomes were recorded. A meta-analysis was used to combine the mean postoperative functional outcomes using a random-effects model.

RESULTS

Overall, there were a total of 36 studies and 4744 patients included in this review. The mean MINORS score was 10.7 (range 8-13) for non-comparative studies and 17.6 (range 15-20) for comparative studies. Three comparative studies in 1302 patients examining the proportion of patients reaching the MCID for the mHHS score in patients undergoing interportal capsulotomy with either capsular repair or no repair found that the capsular repair group had a higher odds ratio of reaching the MCID at 1.46 (95% CI 0.61-3.45, I² = 67%, Fig. 2, Table 3); however, this difference was not significant with a p value of 0.39. When looking at only level 1 and 2 studies, four studies in 1308 patients reporting on the mHHS score in patients undergoing capsular closure regardless of capsulotomy type, found a pooled standardized mean difference in the mHHS score of 2.1 (95% CI 1.7-2.55, I² = 70%, Fig. 3), while four studies in 402 patients reporting on the mHHS score in patients not undergoing capsular closure regardless of capsulotomy type found a pooled standardized mean difference in the mHHS score of 1.46 (95% CI 1.2-1.7, I² = 30%, Fig. 4).

CONCLUSION

This review may demonstrate improved postoperative outcomes in patients undergoing complete capsular closure regardless of capsulotomy type based on postoperative mHHS score. Furthermore, this review may suggest improved postoperative outcomes after closure of an interportal capsulotomy. There are limited published outcome data regarding T-type capsulotomy without closure. This review provides surgeons with operative guidance on capsular management strategies when treating patients with FAI lesions arthroscopically.

LEVEL OF EVIDENCE

IV.