Safety measures in hip arthroscopy and their efficacy in minimizing complications: a systematic review of the evidence

During Postless Hip Arthroscopy, Male Patients, High Body Mass Index, Low Beighton Scores, and Limited Range of Motion Require High Traction Force

PURPOSE

To determine the effects of demographic and anatomic factors on traction force required during postless hip arthroscopy.

METHODS

A prospectively collected database was retrospectively analyzed on patients undergoing hip arthroscopy by the senior author, including patient sex, age, body mass index (BMI), Beighton Hypermobility Score, hip range of motion in clinic and under anesthesia, hip dysplasia, acetabular version, and femoral version. All patients underwent postless hip arthroscopy under general anesthesia. At the initiation of hip arthroscopy, the traction force required to distract the hip joint was measured before and following interportal capsulotomy. Multiple regression analysis was performed to determine the effects of demographic and anatomic factors on measured distraction force.

RESULTS

In total, 352 hips (114 male, 238 female) were included with a mean age of 32.6 years and a mean BMI of 24.1 kg/m2. Mean initial traction force was 109 lbs and decreased to 94.3 lbs following capsulotomy (P < .0001). The starting traction force was significantly greater in male patients (P < .001), patients with a lack of hypermobility (Beighton Hypermobility Score of 0-2) (P = .026), and in patients with lower abduction (P < .001), lower internal rotation (P = .002), and lower external rotation (P = .012) on multiple regression analysis. When performing a subanalysis divided by sex, male patients with elevated BMI required significantly greater starting traction force (P = .014). Lateral center edge angle, sourcil angle, and the presence of hip dysplasia did not demonstrate a significant correlation with traction force.

CONCLUSIONS

Male patients, patients with reduced preoperative hip range of motion, patients with a lack of joint hypermobility, and male patients with an elevated BMI require greater initial traction force during postless hip arthroscopy.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A High Incidence of Perineal Post-Related Complications After Hip Arthroscopy Is Self-Reported by Patients in Anonymous Online Forums

Purpose

To evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy.

Methods

Public posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person's symptoms and concerns were collected from each post. Descriptive statistics were used to analyze the data.

Results

Twenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Sex information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and 4 posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery.

Conclusions

A high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy preoperatively.

Clinical Relevance

Identifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes.

Traction-related complications in hip arthroscopy for 26 years. A systematic review

The primary aim of the study is to determine the rate of traction-related complications in hip arthroscopy (HA) including perineal compression and distraction injuries, and the secondary objective is to report the incidence of complications in HA found on the studies selected by a systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for data extraction from the PubMed and Cochrane databases obtained in February 2022. Reviewers extracted the title, author, date of publication, number of hips treated and number of complications describing the affected area, nerve and soft tissue injury related to traction. Studies on postless HA and HA combined with other procedures were excluded. Twenty-six years of HA literature was found in the search that included 35 studies and 8126 hips (89% Level IV) that reported the complications found during the procedure and described complications related to traction. A total of 623 hips (7.7%) had some sort of complications during HA, and complications related to traction were in 227 hips (36%). Injuries caused specifically by the perineal compression were in 144 hips (23%) that included the pudendal nerve and soft tissue injury of the groin area. Complications caused by the distraction were in 83 hips (13%) that included sciatic and peroneal nerve injury, numbness or pain of ankle and foot. HA complications occurred in 7.7% of hips treated, which is found in this systematic review. One-third of the complications are related to traction, 23% are caused by perineal compression and 13% are caused by distraction.

The HAR-index: a reliable method for evaluating the risk of total hip arthroplasty conversion after hip arthroscopy for femoroacetabular impingement

PURPOSE

Hip arthroscopy is a growing technique in the treatment of femoroacetabular impingement (FAI), but can sometimes lead to unsatisfactory results such as the early conversion to total hip arthroplasty (THA). The purpose of this study is to describe a new tool for assessing the preoperative risk of THA conversion after hip arthroscopy in patients with FAI.

METHODS

This study is a retrospective analysis of a prospective cohort of 584 patients with FAI who underwent hip arthroscopy at a single centre with a minimum 2 years follow-up. The preoperative variables of these patients were analysed to calculate the risk of each variable for THA. By selecting variables with an area under the receiver operating characteristic (ROC) curve greater than 0.7, a calculator was created to provide a risk index for each patient.

RESULTS

Four variables (age, body mass index, Tönnis score and ALAD) were associated with an increased risk of THA conversion. The optimal cut-off points for each variable were determined, and a risk index was created. The Hip-Arthroplasty-Risk Index (HAR-Index) is a 0-4 points scale obtained from four binary scores of 0 or 1 depending on whether the cut-off point for each variable was reached or not. The increased risk of THA for each HAR-Index value was 1.1%, 6.2%, 17.9%, 55.1% and 79.3% respectively. The HAR-Index showed a very good predictive capacity with an area under the ROC curve of 0.89.

CONCLUSION

The HAR-Index is a simple and practical tool for practitioners to make more informed decisions about performing hip arthroscopy in patients with FAI. With a very good predictive capacity, the HAR-Index can help to reduce the rate of conversion to THA.

LEVEL OF EVIDENCE

Level III.

Postless Arthroscopic Hip Preservation Can be Adequately Performed Using Published Techniques

Purpose

To identify and evaluate techniques used for postless hip arthroscopy.

Methods

A narrative review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify surgical technique articles or clinical studies describing techniques for the use of postless hip arthroscopy. Specific items sought for analysis included hip arthroscopy for femoroacetabular impingement including cam or pincer-type lesions, surgical time, traction time, traction force, bed Trendelenburg angle, intraoperative techniques, and postoperative outcomes, including complications. Exclusion criteria included any postless techniques used for open hip surgeries such as periacetabular osteotomy, sports hernia, peritrochanteric work, gluteus medius repair, ischiofemoral impingement, hamstring repair, or need for intraoperative conversion from postless to posted technique.

Results

Ten studies (1 Level III, 3 Level IV, 6 Level V), published from 2007 to 2021, were analyzed (1,341 hips, 51.5% male, mean age ranged from 16.0 to 66.0 years). In 4 studies, Trendelenburg position with a foam pad (The Pink Pad; Xodus Medical, Inc.) was used at 5 to 20°. Six of 10 studies contained no clinical results. The average traction force and time ranged from 65.0 to 88 pounds and 31.0 to 73.5 minutes, respectively. The remaining studies used the yoga mat technique, the Tutankhamun technique, the beanbag technique, and the Hip Arthroscopy Post-less Procedure Impingement technique. There was only one incident of pudendal neurapraxia, which resolved spontaneously at 6 weeks without complication. Sufficient distraction was able to be obtained using postless traction in all cases.

Conclusions

Postless hip arthroscopy may adequately be performed with a variety of techniques. Obtaining adequate traction and countertraction may be achieved through these postless methods.

Clinical Relevance

Given the potential serious complications that may result from use of a perineal post, it is important for surgeons to be aware of postless techniques that may be used effectively for hip arthroscopy.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

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.

Comparison of Complications in X-Ray Versus Ultrasound-Guided Hip Arthroscopy

PURPOSE

To report the complication rates and frequency of iatrogenic injury to the cartilage and labrum when using an ultrasound-guided hip arthroscopic technique compared with the standard x-ray-guided technique.

METHODS

In this retrospective cohort study of prospectively collected data, intraoperative videos were evaluated for iatrogenic injury during portal establishment. Postoperative complications and revision procedures were monitored for 12 months.

RESULTS

The study included 460 patients, with 38% in the ultrasound cohort. Video review showed a 2% complication rate of femoral head scuffing and <2% labral injury in both techniques, with no significant difference between techniques in cartilage injury (P = .90) or labrum puncture (P = .41). Six patients underwent revision procedures, 2 in the x-ray group and 6 in the ultrasound group. One patient developed a deep infection postoperatively. There were no other major complications.

CONCLUSION

Ultrasound-guided hip arthroscopy is a safe alternative to the standard x-ray-guided procedure in patients with a BMI less than 35.

LEVEL OF EVIDENCE

III, retrospective cohort.

Nerve lesions during arthroscopic procedure: a literature overview

Arthroscopy is more and more popular. Although minimally-invasive, it's not completely free of complications as nerves lesions which can be invalidating for the patient and frustrating for the surgeon with significant economic, psychological and medico-legal implications. The purpose was to review the literature about nerve injuries related to arthroscopy. A scientific literature review was performed in PubMed/Medline, including articles dealing with cases of iatrogen lesions of the peripheral nerves occurred during arthroscopic procedures. These lesions are mainly due to direct damage by nerve section while cutting for making the portals or during surgical maneuvers, or indirect damage due to traction or pressure mechanisms especially for errors in patient positioning. Also the tourniquet can lead to compression and ischemic nerve injury. Arthroscopy can cause both transient and permanent neurological lesions manifested with dysesthesia up to paralysis according to Seddon's classification in neuroapraxia, axonotmesis and neurotmesis. Incidence of complications in general and of nerve injuries during arthroscopy are reported by joint. A rigorous respect for surgical technique and all perioperative precautions, particularly in relation to the positioning of the patient, greatly reduce the risk of nerve injury. The suggested waiting time before surgical nerve revision is 6 months. In the meanwhile the patient should perform physiotherapy constantly and improvements should be evaluated with clinical examination and electromyography 15-20 days after the lesion, and thereafter at 3 and 6 months.

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

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

Hip Arthroscopy With and Without A Perineal Post: A Comparison of Early Postoperative Pain

PURPOSE

To compare postoperative pain and early recovery after hip arthroscopy with and without a perineal post for joint distraction.

METHODS

We retrospectively reviewed a consecutive series of patients who underwent hip arthroscopy before and after the adoption of a postless technique. Patients who underwent concurrent periacetabular or femoral osteotomy were excluded. Demographic information, procedure variables, and visual analog scale (VAS) pain scores were recorded. Analgesic medications given were converted to morphine milligram equivalents (MME) for comparison. Uni- and multivariate analyses were conducted to compare total MME, postoperative pain, and time to discharge between groups.

RESULTS

One hundred patients were in each group. The overall age (mean ± standard deviation) was 26.5 ± 9.9 years (Post [P]: 57 females; No Post [NP]: 68 females). Total operative time (P 100.4 ± 17.9 minutes vs NP 89.1 ± 25.5 minutes, P = .0004), traction time (P 45.8 ± 10.3 minutes vs NP 40.9 ± 11.1 minutes, P = .0017), and operating room time (P 148.8 ± 19.3 minutes vs NP 137.3 ± 25.8 minutes, P = .0005) were found to be shorter in the NP group. Total MME, and final VAS pain scores in the PACU were similar between both groups (MME, P = .1620; VAS, P = .2139). Time to discharge was significantly shorter in the NP group (P 207.2 ± 58.8 vs NP 167.5 ± 47.9, P < .0001). Patient age (≥25 years) (65.2 ± 18.1 vs 59.8 ± 15.7 [MME], P = .0269) and elevated body mass index (≥25) (65.1 ± 17.1 vs 59.3 ± 16.4 [MME], P = .0164) were factors associated with greater total MME consumption. Female sex was associated with higher postoperative VAS pain scores (FM 4.1 ± 1.6 vs M 3.4 ± 1.8 P = .0027).

CONCLUSIONS

Adoption of the postless technique did not result in prolonged operating room or operative time. Overall, both groups had similar postoperative pain, however, the time from surgery to hospital discharge was shorter in the postless group.

LEVEL OF EVIDENCE

III, retrospective comparison study.

Evaluation of primary hip arthroscopy complications in mid-term follow-up: a multicentric prospective study

INTRODUCTION

Hip arthroscopy is a common procedure in hip preservation surgery. Its complication rate is relatively low. This prospective multicentric study evaluates complication rate in patients undergoing primary hip arthroscopy.

MATERIALS AND METHODS

The study cohort consisted of 908 patients mean age of 37 years (14-67 years). Patients were prospectively included in the study in the years 2009-2017. All complications were recorded and evaluated. The minimum follow-up was 36 months. Results were statistically evaluated and risk factors for complications were identified.

RESULTS

The overall complication rate was 7.3% (67/908 cases), the minor complication rate of 4.9% (45/908 cases) and the major complication rate 2.4% (22/908 cases). The most common severe complications were iatrogenic cartilage damage and instrument breakage, while the most common minor complications were perineal hypoaesthesia and heterotopic ossifications. The conversion rate to total hip replacement was 4.2% (39/908 patients).

CONCLUSION

Hip arthroscopy is a safe procedure with low complication rates. Surgeon training and experience greatly influence the complication rates.

Preoperative risk factors in hip arthroscopy

PURPOSE

Arthroscopic surgery is a usual technique to repair hip femoroacetabular impingement. Correlation exists among surgical indication, postoperative evolution, the final result, and the necessity of prosthesis in the near future. The assessment of specific parameters allowing us to evaluate the prognosis becomes vital to improve the results. The objective of this study is to check the variables found in patients with femoroacetabular impingement (FAI) treated with hip arthroscopy, and determine which of these variables would serve as key indicators in predicting the need for subsequent arthroplasty.

METHODS

Data from FAI surgical indications (age, weight, height, BMI, gender, side, radiographic Tönnis degree, cartilage lesion degree by Acetabular Labrum Articular Disruption (ALAD) degree, VAS value, HOS, mHHS and WOMAC) were collected from cases which should have had a minimum monitoring period of 2 years from 2007 to 2017. The results of the group which needed prosthesis were compared to the results of the ones who did not.

RESULTS

Among 452 patients who were monitored for an average of 5.8 years, 82 (18.1%) required conversion to prosthesis. The variables that indicated relatively high risk were fourth-degree acetabular labrum articular disruption (ALAD) chondral injury, preoperative radiographic Grade 2 Tönnis classification, age of over 55 years, WOMAC over 45 points, and HOS-ADL under 50 points. There were no significant differences between side, gender, VAS level, nor HOS.

CONCLUSIONS

The presence of chondral injuries such as acetabular labrum articular disruption (ALAD) 4, radiographic Grade 2 Tönnis classification, higher age, higher BMI, and worse WOMAC, along with mHHS and HOS-ADL preoperative results, are factors which lead to a poor prognosis following FAI hip arthroscopic surgery, increasing the risk of prosthetic conversion in the short or medium term.

LEVEL OF EVIDENCE

Level IV.

Limitations of Postless Hip Arthroscopy for a Patient with Coxa Profunda: A Case Report

CASE

A 27-year-old man with coxa profunda and a right acetabular labral tear presented for surgical re-evaluation after a postless arthroscopic labral repair was attempted at an outside institution and aborted because of inadequate distraction during portal placement. Arthroscopic labral repair with a perineal post was subsequently performed without complications.

CONCLUSION

Indications and limitations of postless hip distraction are seldom discussed in the literature. This report examines possible limitations of postless hip distraction for a patient with coxa profunda. Careful radiographic evaluation of hip anatomy may be essential for patients with deep hip sockets to determine the best-suited distraction technique.

The Learning Curve for Hip Arthroscopic Surgery: A Prospective Evaluation With 2-Year Outcomes in Patients With Femoroacetabular Impingement

Background

The use of hip arthroscopic surgery in the treatment of femoroacetabular impingement (FAI) is increasing, but it is universally known as a technically demanding procedure with a "steep" learning curve. There are limited data investigating the correlation between surgeon experience and patient-reported outcomes (PROs) as well as procedure and traction times.

Purpose

To prospectively evaluate the relationship between surgeon experience and PROs after hip arthroscopic surgery for the treatment of FAI.

Study Design

Cohort study; Level of evidence, 2.

Methods

A total of 190 patients undergoing primary hip arthroscopic surgery for FAI were prospectively enrolled during a sports medicine fellowship-trained surgeon's first 36 months of practice. A radiographic evaluation as well as PRO surveys including the 12-Item Short Form Health Survey (SF-12), the modified Harris Hip Score (mHHS), and the Hip disability and Osteoarthritis Outcome Score (HOOS) were administered preoperatively and at 2 years postoperatively. Logistic regression as well as analysis of variance was performed to evaluate for correlations between surgical experience and PROs, procedure time, and traction time.

Results

Of the 190 patients, 168 (88%; mean age, 35.3 ± 9.6 years; mean body mass index, 25.07 ± 3.98) completed a 2-year follow-up and were included for analysis. The mean procedure time was 91.5 ± 23.9 minutes, and the mean traction time was 54.0 ± 17.7 minutes. Patients demonstrated significant improvements at 2 years after surgery for all PRO scores (mHHS, HOOS, and SF-12 physical component summary; P < .001), except the SF-12 mental component summary, which had no change (P = .43). The procedure time significantly decreased after 70 cases, while the traction time continued to decrease until 110 cases (R ² = 0.99; P < .0001). There was no correlation between increasing case volume and 2-year PRO scores (P > .2 for mHHS, HOOS, and SF-12). There was also no difference with increasing case volume and amount of improvement from preoperative to 2-year postoperative PRO scores for the SF-12 and HOOS. Case volume did not affect the complication rate, as this cohort experienced 4 minor cases of neurapraxia.

Conclusion

Surgical efficiency in hip arthroscopic surgery for the treatment of FAI was maximized after 110 cases in this cohort. However, significant PRO improvements can be achieved early in a surgeon's practice prior to maximizing surgical efficiency.

Stepwise Safe Access in Hip Arthroscopy in the Supine Position: Tips and Pearls From A to Z

Hip arthroscopy is rapidly growing as a treatment with good outcomes for pathologic conditions such as femoroacetabular impingement syndrome and labral tears. At the same time, it is one of the most technically challenging and demanding procedures in orthopaedics with a technically demanding skill. The first challenge is to safely access the joint, which requires accurate anatomical knowledge, a strong sense of spatial orientation, and repeated practice. Iatrogenic chondrolabral injury has been reported as the most common complication in hip arthroscopy and most frequently occurs during hip joint access. As such, basic foundations cannot be overstated. These complications can be minimized with adequate patient positioning, reproducible hip joint access techniques, and proper portals placement. Nonetheless, these three points are perhaps the greatest hurdles that orthopaedic surgeons face when entering the hip arthroscopy field. In this review, we outlined a stepwise approach for a safe access to hip arthroscopy.

Staged Bilateral Hip Arthroscopy Compared With a Matched Unilateral Hip Arthroscopy Group: Minimum 2-Year Follow-Up

PURPOSE

To determine the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) at 2-year follow up in patients who underwent staged bilateral hip arthroscopy versus age-, sex-, and body mass index-matched patients who underwent unilateral hip arthroscopy.

METHODS

Patients who underwent staged bilateral primary hip arthroscopy between January 2007 and December 2017 for the indication of femoroacetabular impingement (FAI) with a minimum 2-year follow-up were identified. The control group comprised patients who underwent a unilateral hip arthroscopy for FAI. The mHHS and the NAHS were analyzed.

RESULTS

Forty-two patients (84 hips) in the bilateral group were matched with 84 patients (84 hips) in the unilateral group. Both groups had significantly improved mHHS and NAHS when comparing preoperative scores with postoperative scores (bilateral group mHHS: 45.5 ± 15.1 to 81.7 ± 17.6, P < .0001, bilateral group NAHS: 49.5 ± 13.8 to 83.6 ± 20.0, P < .0001, unilateral group mHHS 48.5 ± 13.8 to 83.6 ± 15.9, P < .0001, unilateral group NAHS 48.8 ± 12.0 to 85.0 ± 16.6, P < .0001). The patient-acceptable symptomatic state was achieved in 57 hips (68%) in the bilateral group versus 62 hips (74%) in the unilateral group, P = .4. Patients with bilateral hip arthroscopy who had <17 months between index procedure and contralateral hip arthroscopy had significantly better mHHS and NAHS (85.5 ± 18.4 vs 75.71 ± 14.4, P = .013 for mHHS and 88.1 ± 17.1 vs 76.2 ± 22.4, P = .0074 for NAHS).

CONCLUSIONS

Bilateral hip arthroscopy for the indication of FAI has improved mHHS and NAHS at 2 years of follow up compared to baseline. There was no difference in 2-year mHHS and NAHS in patients who underwent bilateral hip arthroscopy and unilateral hip arthroscopy. Patients in the bilateral hip arthroscopy group that had the contralateral surgery longer than 17 months from index procedure had lower 2 year follow up mHHS and NAHS scores than those that underwent the second surgery within 17 months of the index procedure.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Risk factors for 30-day readmission following hip arthroscopy

PURPOSE

Hip arthroscopy is known to be safe with low rates of postoperative complications. The purpose of this study is to evaluate hip arthroscopy cases in a national surgical database to identify risk factors associated with readmission.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2012 to 2016 for current procedural terminology billing codes related to hip arthroscopy. International Classification of Diseases diagnostic codes were used to exclude cases involving infection, fracture, or open procedures. Univariate and multivariate analyses were performed to identify risk factors associated with 30-day readmission.

RESULTS

1493 patients were identified who had undergone hip arthroscopy. The most common procedures were labral resection or chondroplasty (n = 589, 39.5%) and femoroplasty (n = 527, 35.3%). The 30-day complication rate was 1.7% and the most common complications following the procedure were bleeding (n = 12, 0.8%) superficial infections (n = 5, 0.3%), and returning to the operating room (n = 4, 0.3%). The 30-day readmission rate was 1.3%. On multivariate analysis, hypertension requiring anti-hypertensive medication (odds ratio [OR], 3.5; 95% confidence interval [CI], 1.4-8.7) and chronic corticosteroid or immunosuppressant use (OR 7.2; 95% CI 1.9-26.7) were identified as independent risk factors for readmission. There was no difference in complication rates when hip arthroscopy was performed with isolated femoroplasty (n = 340), isolated acetabuloplasty (n = 103), both (n = 187) or neither (n = 863).

CONCLUSION

These findings confirm that the 30-day readmission (1.3%) and complication rate (1.7%) are low for isolated hip arthroscopy procedures; however, hypertension and chronic steroid use are independent risk factors for readmission.

LEVEL OF EVIDENCE

Retrospective comparative study, Level III.

Successful Hip Arthroscopy Using Postless Distraction in a Professional Basketball Player: A Case Report

CASE

A 36-year-old 7'0' male professional basketball player presented with hip pain and radiographic imaging consistent with femoroacetabular impingement syndrome and a labral tear. Hip arthroscopy was performed with the patient positioned supine on a postless distraction table to negate the risk of pudendal nerve and perineal skin complications. Hip distraction was achieved with only 40 lbs (18.14 kg) of distraction force. Labral repair and cam osteochondroplasty were safely performed without complication.

CONCLUSIONS

This case is the first to demonstrate that postless distraction may be considered for patients at end ranges of height that exceed the limitations of common hip arthroscopy tables.

Unplanned Admissions Following Hip Arthroscopy: Incidence and Risk Factors

PURPOSE

To determine the rate of and risk factors for 30-day unplanned admissions following hip arthroscopy in a U.S.

METHODS

Patients undergoing hip arthroscopy were identified in the American College of Surgeons National Surgical Quality Improvement Program database using validated Current Procedural Terminology and International Classification of Diseases, Ninth Revision and Tenth Revision codes. Patient demographics, comorbidities, preoperative laboratory values, surgical details, and postoperative outcomes were compared between patients with unplanned admissions and those without. Univariate analysis comparing study cohorts was performed using 2-tailed Student t tests with Levene's test for equality of variance or χ²/Fisher exact tests as appropriate. Using variables that were significant in the univariate analysis, we created Cox proportional hazard models to identify independent predictors for unplanned admission.

RESULTS

A total of 1931 cases of hip arthroscopy were identified. There were 18 cases of unplanned admissions within 30 days of index procedure (0.9%). The median time to unplanned admission was 14.5 days (interquartile range: 3.875-25.125 days). The most common reasons for admission were surgical-site infection (11.1%), wound complications (11.1%), and thromboembolic events (11.1%). There were 4 patients who required reoperation (22.2%). There were 7 cases (39.0%) that were readmitted for reasons unrelated to the index hip arthroscopy procedure. Multivariate analysis identified increasing body mass index, chronic corticosteroid use, and perioperative blood transfusion as factors independently associated with increased risk for unplanned admission.

CONCLUSIONS

There exists a low incidence of 30-day unplanned admission, predominantly secondary to surgical-site infections, wound complications, and thromboembolic events. Independent risk factors for unplanned admission include greater body mass index, chronic corticosteroid use, and perioperative transfusions.

LEVEL OF EVIDENCE

Level III Retrospective Cohort Study.

Perineal Pressure During Hip Arthroscopy Is Reduced by Use of Trendelenburg: A Prospective Study With Randomized Order of Positioning

BACKGROUND

The use of traction during hip arthroscopy is commonly used to provide safe joint access and to improve visualization. However, traction during hip arthroscopy has been associated with complications ranging from transient neuropraxias to devastating soft-tissue necrosis. Trendelenburg positioning may be helpful, but the degree to which this is true is not well understood.

QUESTIONS/PURPOSES

To determine whether there would be a reduction in perineal pressure at 5°, 10°, and 15° of Trendelenburg compared with baseline (0° of Trendelenburg) while in the modified supine position during hip arthroscopy.

METHODS

A consecutive cohort of 50 patients treated with hip arthroscopy by a single, high-volume orthopaedic surgeon was analyzed. There were 30 females and 20 males in this study, with a mean age of 36 ± 16 years (range, 14 to 66 years); mean BMI was 26 kg/m. In the operating room, patients were placed in the modified supine position on a traction extension table with a well-padded perineal post. A standard blood pressure cuff was secured to the post to measure pressure exerted on the perineum as traction was applied to distract the hip. For each patient, pressure against the perineum was measured at four different positions using a digital level: 0°, 5°, 10°, and 15° of Trendelenburg. These positions were tested in a random order for each patient. Mean pressure was compared within patients under the four-period crossover design using a repeated-measure (mixed) ANOVA model. Examination of the residual error quantile plot showed that the pressure data followed a normal distribution, making the use of a parametric model appropriate. Tests were made for period and order effects.

RESULTS

Compared with baseline (0° or no Trendelenburg) there was a reduction in pressure of 4.4 (15.5%) at 5° of Trendelenburg (p = 0.203), 8 (28%) at 10° of Trendelenburg (p = 0.022) and 13.1 (46%) at 15° (p = 0.006). These results were maintained regardless of the sequence of positions used in each patient (0°, 5°, 10°, 15°).

CONCLUSIONS

Trendelenburg positioning of 10° and 15° during hip arthroscopy resulted in decreased perineal pressure compared with the neutral (0°) position. This technique is intended to harness gravity to exert the majority of countertraction while retaining the perineal post as a backup patient stabilizer. Routine introduction of Trendelenburg during hip arthroscopy reduces perineal pressure against the post, which may decrease complications related to traction and perineal pressure. Future studies should assess whether the observed differences in perineal pressure will reduce the frequency of post-related complications after hip arthroscopy.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Effects of Hip Arthroscopy Without a Perineal Post on Venous Blood Flow, Muscle Damage, Peripheral Nerve Conduction, and Perineal Injury: A Prospective Study

BACKGROUND

Prior reports of hip arthroscopy using a perineal post have established the risks of groin soft tissue injury, sexual dysfunction, and altered lower extremity neurovascular function. These parameters have not been investigated for hip arthroscopy without the use of a perineal post.

PURPOSE

To evaluate the effects of postless hip arthroscopy on lower extremity venous blood flow, nerve conduction, muscle tissue damage, and perineal injury.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients between the ages of 18 and 50 years undergoing an elective unilateral or simultaneous bilateral hip arthroscopy were enrolled. Creatine phosphokinase (CPK)-MM levels and D-dimer levels were obtained preoperatively, immediately postoperatively, and 7 to 12 days postoperatively. Bilateral Doppler ultrasonography of the common femoral vein (CFV) and popliteal vein were conducted intraoperatively. Somatosensory evoked potentials (SSEPs) and transcranial motor evoked potentials (TcMEPs) were measured intraoperatively for the lower limbs. Perineal injury was assessed at 7 to 12 days postoperatively.

RESULTS

35 patients underwent a total of 40 hip arthroscopies. No significant differences were found in venous blood flow between the operative and nonoperative legs for either the CFV or popliteal vein. SSEP monitoring of the peroneal nerve showed no significant reduction when traction was applied to the operative leg, 90.8%, compared with final measurement just before it was removed, 72.4% (P = .09). For TcMEPs measured in the muscles outside of the traction boots, no significant changes were seen in the percentage of cases with abnormal measurements throughout the procedure. CPK-MM levels preoperatively, immediately postoperatively, and 7 to 12 days after surgery were on average 112, 190, and 102 IU/L, respectively (normal, <156 IU/L). No significant relationship was found between abnormal venous flow and altered D-dimer levels. No clinical evidence of nerve or vascular injury was encountered, and no groin soft tissue complications were observed during the study period.

CONCLUSION

Postless hip arthroscopy is safe, without a notable reduction of venous blood flow or alteration of nerve function in the operative leg. Muscle tissue damage is subclinical, transient, and reduced compared with distraction with a post. No cases of perineal injury were observed during the study period.

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

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

Mid-term outcome after arthroscopic treatment of femoroacetabular impingement: development of a predictive score

PURPOSE

To build a post-arthroscopy outcome-predictive score (POPS) associated with the likelihood of lasting benefit after arthroscopic treatment of femoroacetabular impingement (FAI) and based solely on unambiguous preoperative information.

METHODS

A population of 220 FAI patients, operated on with standard techniques by orthopaedic surgeons trained in hip arthroscopy in 6 different centres, was evaluated physically or by telephone interview 2 to 5 years after surgery. The criteria of successful mid-term outcome (SMO) were agreed upon by all authors. A multivariate logistic regression, adjusted for patient's age and centre, was applied to predict SMO. In the model, the variables associated with the outcome were included and the relative ORs (odds ratios) were used to compute the FAI-POPS (FAI - post-arthroscopy outcome-predictive score). A ROC (receiver operating characteristic) curve was plotted and the optimum cut-off was calculated.

RESULTS

155 patients out of 220 showed a successful mid-term outcome. The optimum cut-off of FAI-POPS was calculated to be 6.3 and with this threshold it proved a sensitivity of 0.66 and a specificity of 0.69, a positive predictive value of 0.84 and a negative predictive value of 0.46.

CONCLUSIONS

The standard arthroscopic treatment of FAI resulted in satisfactory persistent symptom relief for about 70% of patients. No or minimal osteoarthritis, short time elapsed from the appearance of symptoms and high preoperative modified Harris Hip Score are independent predictive factors of SMO. The FAI-POPS is obtained as sum of 3 odds ratios corresponding to the above prognostic factors and is a useful predictor of mid-term outcome after conventional arthroscopic FAI treatment.

Hip Arthroscopy Complications Are Rare, but There Is Room for Improvement

Complications are agonizing and leave feelings of inadequacy, insufficiency, or ineptitude. For these and other reasons, complications are not frequently reported in the literature. But reporting of complications is not only cathartic, it can be illuminating. Once out in the daylight, complications can be categorized, quantified, parsed, analyzed, and dissected with the scientific method to yield insight to enable us to prevent complications that we can avoid. Technical innovations have demonstrated ability to solve current problems. Standardizing the reporting of complications allows comparability between centers. Better data lead to better analysis and may decrease the complication rate. Recent investigations published in Arthroscopy and elsewhere have improved our understanding of hip arthroscopy complications, making the procedure safer, more effective, and of higher value.

A Systematic Summary of Systematic Reviews on the Topic of Hip Arthroscopic Surgery

BACKGROUND

There is a rapidly growing body of literature on the topic of hip arthroscopic surgery.

PURPOSE

To provide an overall summary of systematic reviews published on the indications, complications, techniques, outcomes, and information related to hip arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all hip arthroscopic surgery-related systematic reviews published between January 2000 and May 2018 was performed using PubMed, MEDLINE, and the Cochrane Library. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 837 articles were found, of which 85 met the inclusion criteria. Included articles were summarized and divided into 6 major categories based on the subject of the review: femoroacetabular impingement (FAI), non-FAI indications, surgical technique, outcomes, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on hip arthroscopic surgery can provide surgeons with a single source for the most current synopsis of the available literature. As the prevalence of orthopaedic surgeons performing hip arthroscopic surgery increases, updated evidence-based guidelines must likewise be advanced and understood to ensure optimal patient management.

The interface between periacetabular osteotomy, hip arthroscopy and total hip arthroplasty in the young adult hip

Hip pain is highly prevalent in both the younger and the elderly population. In older patients, pain arising from osteoarthritis (OA) is most frequent, whereas in younger patients, non-degenerative diseases are more often the cause of pain. The pain may be caused by hip dysplasia and femoroacetabular impingement (FAI).Abnormal mechanics of the hip are hypothesized by some authors to cause up to 80% of OA in the hip. Therefore, correction of these abnormalities is of obvious importance when treating young patients with hip pain.Hip dysplasia can be diagnosed by measuring a CE angle < 25° on a plain standing radiograph of the pelvis.Dysplastic or retroverted acetabulum with significant symptoms should receive a periacetabular osteotomy (PAO).FAI with significant symptoms should be treated by adequate resection and, if necessary, labrum surgery.If risk factors for poor outcome of joint-preserving surgery are present (age > 45 to 50 years, presence of OA, joint space < 3 mm or reduced range of motion), the patient should be offered a total hip arthroplasty (THA) instead of PAO.THA can be performed following PAO with outcomes similar to a primary THA.Hip arthroscopy is indicated in FAI (cam and pincer) and/or for labral tears. Cite this article: EFORT Open Rev 2018;3:408-417. DOI: 10.1302/2058-5241.3.170042.

Assessing the Readability of Online Information About Hip Arthroscopy

PURPOSE

To investigate the current readability of online information pertaining to hip arthroscopy.

METHODS

The terms "hip arthroscopy" and "hip scope" were entered into the advanced search functions of Google, Yahoo!, and Bing on March 25, 2017, and results from the first 3 pages were analyzed. Results were required to be unique, accessible websites with information about hip arthroscopy conveyed primarily via analyzable text. Two reviewers applied inclusion criteria to the initial 97 results, discussing to reach consensus in cases of disagreement. Overall, 60 unique results were reviewed with 48 meeting inclusion criteria. Websites were categorized as physician-sponsored, academic, commercial, governmental and nonprofit organization (NPO), or unspecified. Readability was measured via 6 different indices: the Flesch-Kincaid grade level (FKGL), Flesch Reading Ease (FRE), Gunning Fog Score, SMOG Index, Coleman-Liau Index (CLI), and Automated Readability Index (ARI) along with an average grade level and readability classification score.

RESULTS

Forty-eight unique websites were assessed for readability, with physician-sponsored webpages composing the majority (47.92%) followed by academic sources (35.42%). The webpages' average grade level, incorporating information from all 6 metrics, was 12.79 ± 1.98.

CONCLUSIONS

The current readability of online information pertaining to hip arthroscopy is at an inappropriately high reading level compared with the sixth-grade level recommended by the American Medical Association and National Institutes of Health, thus introducing significant barriers to understanding for many patients. Online materials should be edited to reduce word and sentence length and complexity, use simpler terms, and minimize use of passive voice to facilitate patient knowledge acquisition and understanding of online information about hip arthroscopy.

CLINICAL RELEVANCE

This study shows that the current readability of online information on hip arthroscopy exceeds the suggested sixth-grade reading level. It also emphasizes the need for simplifying written materials and offers specific suggestions on doing so to increase accessibility of information for patients.

Is It Safe to Perform an Early Arthroscopy After a Traumatic Hip Dislocation With an Associated Pelvic Ring Injury? Report of Our Technique

Hip arthroscopy is useful in the treatment of several intra-articular pathologies, however, its use in high-energy hip and pelvis injuries raises concerns about fluid extravasion and stability of the pelvic ring. We present our arthroscopic surgical technique (initial access to the peripheral compartment) to remove intra-articular loose bodies and treat associated lesions, as well as our concerns with the technique, in case of a traumatic hip dislocation associated with a contralateral pelvic ring injury.

Impingement around the hip: beyond cam and pincer

In this review, we bring to the attention of the reader three relatively unknown types of hip impingement. We explain the concept of low anterior inferior iliac spine (AIIS) impingement, also known as sub-spine impingement, ischio-femoral impingement (IFI) and pelvi-trochanteric impingement. For each type of impingement, we performed a search of relevant literature.We searched the PubMed, Medline (Ovid) and Embase databases from 1960 to March 2016. For each different type of impingement, a different search strategy was conducted.In total, 19 studies were included and described. No data analysis was performed since there was not much comparable data between studies.An overview of symptoms, clinical tests and possible surgical treatment options for the three different types of extra-articular impingement is provided.Several disorders around the hip can cause similar complaints. Therefore, we plead for a standardized classification. In young and athletic patients, in particular, there is much to gain if hip impingement is diagnosed early. Cite this article: EFORT Open Rev 2018;3:30-38. DOI: 10.1302/2058-5241.3.160068.

Hip Distraction Without a Perineal Post: A Prospective Study of 1000 Hip Arthroscopy Cases

BACKGROUND

Hip arthroscopy has traditionally been performed with a perineal post, resulting in various groin-related complications, including pudendal nerve neurapraxias, vaginal tears, and scrotal necrosis.

PURPOSE

To assess the safety of a technique for hip distraction without the use of a perineal post.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

We prospectively analyzed a consecutive cohort of 1000 hips presenting to a dedicated hip preservation clinic; all patients had hip pain and were subsequently treated with hip arthroscopy. Demographic variables, hip pathology, and lateral center edge angle were recorded for each case. In the operating room, the patient's feet were placed in traction boots in a specifically designed distraction setup, and the operative table was placed in varying degrees of Trendelenburg. With this technique, enough resistance is created by gravity and friction between the patient's body and the bed to allow for successful hip distraction without the need for a perineal post. In a subset of 309 hips (n = 281 patients), the degrees of Trendelenburg as well as the distraction force were analyzed.

RESULTS

The mean ± SD Trendelenburg angle used among the subset of 309 hips was 11° ± 2°. The mean initial distraction force necessary was 90 ± 28 lb, which decreased to 65 ± 24 lb by 30 minutes after traction initiation ( P < .0001). The most important variables in determining initial force for this cohort of patients were, in order of magnitude, sex ( P < .0001), weight ( P < .0001), and lateral center edge angle ( P < .01). No groin-related complications occurred among the entire cohort of patients, including soft tissue or nerve-related complications. The rate of deep venous thrombosis was 2 in 1000.

CONCLUSION

The use of the Trendelenburg position and a specially designed distraction setup during hip arthroscopy allows for safe hip distraction without a perineal post, thereby eliminating groin-related soft tissue and nerve complications. Certain patient variables can be used to estimate the required distraction force and inclination angle with this method.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, case-control study.

Venous Thromboembolism Events After Hip Arthroscopy: A Systematic Review

PURPOSE

The purpose of this systematic literature review focused on hip arthroscopy was to (1) report the venous thromboembolism (VTE) event incidence in patients who receive VTE prophylaxis and those who do not, (2) report how VTE prophylaxis is currently being administered, and (3) report operative and patient-related risk factors for VTE identified in the literature.

METHODS

The electronic databases MEDLINE, Embase, and PubMed were searched from database inception to October 10, 2016, and screened in duplicate for relevant studies. Data were collected regarding VTE prophylaxis, traction use, surgical time, VTE incidence, patient and operative factors, and postoperative weight bearing and rehabilitation. Study quality was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria.

RESULTS

Outcome analyses included 14 studies that involved 2,850 patients (2,985 hips). The weighted mean follow-up period was 19 ± 8 months, ranging from 7 days to 103 months. The weighted mean age was 40.7 ± 7 years, ranging from 6 to 82 years, and 39.6% of patients were male patients. The overall weighted proportion of VTE events after hip arthroscopy found in 14 included studies was 2.0% (95% confidence interval, 0.01%-4.1%), with 25 VTE events. Several studies reported patient risk factors, which included increased age, increased body mass index, prolonged traction time, and use of oral contraceptives.

CONCLUSIONS

The use and efficacy of VTE prophylaxis are highly under-reported within hip arthroscopy. The low incidence of VTE events found in this review (2.0%) suggests that prophylaxis may not be necessary in low-risk patients undergoing hip arthroscopy; however, the true rate may be under-reported. Current literature suggests that prophylaxis is typically not prescribed. Early mobility and postoperative rehabilitation may also help to further mitigate the risk of VTE events, but use of these strategies needs further prospective evaluation.

LEVEL OF EVIDENCE

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

Do Arthroscopic Fluid Pumps Display True Surgical Site Pressure During Hip Arthroscopy?

PURPOSE

To report on the accuracy of 5 commercially available arthroscopic fluid pumps to measure fluid pressure at the surgical site during hip arthroscopy.

METHODS

Patients undergoing hip arthroscopy for femoroacetabular impingement were block randomized to the use of 1 of 5 arthroscopic fluid pumps. A spinal needle inserted into the operative field was used to measure surgical site pressure. Displayed pump pressures and surgical site pressures were recorded at 30-second intervals for the duration of the case. Mean differences between displayed pump pressures and surgical site pressures were obtained for each pump group.

RESULTS

Of the 5 pumps studied, 3 (Crossflow, 24K, and Continuous Wave III) reflected the operative field fluid pressure within 11 mm Hg of the pressure readout. In contrast, 2 of the 5 pumps (Double Pump RF and FMS/DUO+) showed a difference of greater than 59 mm Hg between the operative field fluid pressure and the pressure readout.

CONCLUSIONS

Joint-calibrated pumps more closely reflect true surgical site pressure than gravity-equivalent pumps. With a basic understanding of pump design, either type of pump can be used safely and efficiently. The risk of unfamiliarity with these differences is, on one end, the possibility of pump underperformance and, on the other, potentially dangerously high operating pressures.

LEVEL OF EVIDENCE

Level II, prospective block-randomized study.

PERFECTED enhanced recovery (PERFECT-ER) care versus standard acute care for patients admitted to acute settings with hip fracture identified as experiencing confusion: study protocol for a feasibility cluster randomized controlled trial

BACKGROUND

Health and social care provision for an ageing population is a global priority. Provision for those with dementia and hip fracture has specific and growing importance. Older people who break their hip are recognised as exceptionally vulnerable to experiencing confusion (including but not exclusively, dementia and/or delirium and/or cognitive impairment(s)) before, during or after acute admissions. Older people experiencing hip fracture and confusion risk serious complications, linked to delayed recovery and higher mortality post-operatively. Specific care pathways acknowledging the differences in patient presentation and care needs are proposed to improve clinical and process outcomes.

METHODS

This protocol describes a multi-centre, feasibility, cluster-randomised, controlled trial (CRCT) to be undertaken across ten National Health Service hospital trusts in the UK. The trial will explore the feasibility of undertaking a CRCT comparing the multicomponent PERFECTED enhanced recovery intervention (PERFECT-ER), which acknowledges the differences in care needs of confused older patients experiencing hip fracture, with standard care. The trial will also have an integrated process evaluation to explore how PERFECT-ER is implemented and interacts with the local context. The study will recruit 400 hip fracture patients identified as experiencing confusion and will also recruit "suitable informants" (individuals in regular contact with participants who will complete proxy measures). We will also recruit NHS professionals for the process evaluation. This mixed methods design will produce data to inform a definitive evaluation of the intervention via a large-scale pragmatic randomised controlled trial (RCT).

DISCUSSION

The trial will provide a preliminary estimate of potential efficacy of PERFECT-ER versus standard care; assess service delivery variation, inform primary and secondary outcome selection, generate estimates of recruitment and retention rates, data collection difficulties, and completeness of outcome data and provide an indication of potential economic benefits. The process evaluation will enhance knowledge of implementation delivery and receipt.

TRIAL REGISTRATION

ISRCTN, 99336264 . Registered on 5 September 2016.

Hip arthroscopy utilization and associated complications: a population-based analysis

The purpose of this study is to review the trends in hip arthroscopy using data from a statewide database, focusing on utilization rates, patient demographics and complication rates. The Statewide Planning and Research Cooperative System (SPARCS) database for New York State was queried for cases of hip arthroscopy from 1998 to 2012. Patient demographics and procedural details were collected. Patients were subsequently reviewed for complications and readmissions within 30 and 90 days. In total, 12 194 hip arthroscopy procedures were performed by 295 surgeons in 137 centers between 1998 and 2012. There was a 95-fold increase in the annual frequency of hip arthroscopy procedures between 1998 (n = 24) and 2012 (n = 2296). Thirty-day complication rates were 0.2% (n = 19), whereas the 90-day complication rate was 0.3% (n = 30). The all-cause 30-day readmission rate was 0.5% (n = 66), whereas the 90-day rate was 1.6% (n = 200). The number of surgeons performing hip arthroscopy increased 7-fold over the observation period. However, only 14.9% (n = 44) of surgeons performed more than 30 procedures annually. Lower volume surgeons (<102 cases/year) demonstrated significantly higher 90-day readmission rates, compared with higher volume surgeons (>163 cases/year, P < 0.0060); however, complication rates and readmission rates did not differ based on surgeon volume. Our findings confirm our hypothesis, demonstrating a significant increase in utilization of hip arthroscopy in the State of New York. We did not identify an associated increase in annual complication rates as hypothesized with increasing utilization, although there was an association of higher readmission rates among lower volume surgeons. Further study is needed to define rates of failure requiring revision hip arthroscopy or conversion to arthroplasty, and to clarify the relationship between complication rates and surgeon volume and case complexity.

Level of Evidence: III, retrospective cohort series.

Editorial Commentary: Fluid Extravasation in Hip Arthroscopy-A Tough Case Just Got Much Worse

Hip arthroscopy has its complications like any other surgery, but abdominal compartment syndrome is unique to the hip and is a complication with devastating consequences. Avoidance is the rule.

Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013

BACKGROUND

The utilization of hip arthroscopy continues to increase in the United States. The purpose of this study was to examine trends in hip arthroscopy procedures and outcomes.

METHODS

We performed a retrospective cohort study using Optum Labs Data Warehouse administrative claims data. The cohort comprised 10,042 privately insured enrollees aged 18-64 years who underwent a hip arthroscopy procedure between 2005 and 2013. Utilization trends were examined using age-specific, sex-specific, and calendar-year-specific hip arthroscopy rates. Outcomes were examined using the survival analysis methods and included subsequent hip arthroscopy and total hip arthroplasty (THA).

RESULTS

Hip arthroscopy rates increased significantly over time from 3.6 per 100,000 in 2005 to 16.7 per 100,000 in 2013. The overall 2-year cumulative incidence of subsequent hip arthroscopy and THA was 11% and 10%, respectively. In the subset of patients in whom laterality of the subsequent procedure could be determined, about half of the subsequent hip arthroscopy procedures (46%) and almost all of the THA procedures (94%) were on the same side. Decreasing age was significantly associated with the risk of subsequent arthroscopy (P < .01), whereas increasing age was significantly associated with the subsequent risk of THA (P < .01). The 5-year cumulative incidence of THA reached as high as 35% among individuals aged 55-64 years.

CONCLUSION

The utilization of hip arthroscopy procedures increased dramatically over the last decade in the 18-64-year-old privately insured population, with the largest increase in younger age-groups. Future studies are warranted to understand the determinants of the large increase in utilization of hip arthroscopy and outcomes.

Clinical results of arthroscopic surgery in patients over 50 years of age-what viability does it have as a joint preservative surgery?

BACKGROUND

To identify whether hip arthroscopy is a suitable option for treating hip pain in elderly patients and investigate the clinical outcomes of hip arthroscopic surgery for labrum tear and/or osteoarthritis in patients over 50 years of age.

METHODS

Between August 2009 and May 2014, a series of 23 patients (6 men and 17 women) with a mean age of 59 years underwent arthroscopy. We retrospectively examined the clinical records, radiographs, and outcome questionnaires from all patients. The mean follow-up period was 28 months.

RESULTS

The mean Japan Orthopedic Association hip score after surgery improved by a statistically significant amount. Eight patients (34.8%) were noted to have a progression of osteoarthritis (OA) diagnosed by radiograph, and one underwent THA after 13 months following arthroscopic surgery. The patients in which OA progression was noted were identified as having radiographical OA preoperatively and acetabular cartilage damage in the arthroscopic findings.

CONCLUSIONS

Arthroscopic surgery performed in selected patients over 50 years of age might be beneficial if classified as Tönnis grade 0 preoperatively and/or classified as Outerbridge grade II in the arthroscopic findings.

Hip arthroscopy complications regarding surgery and early postoperative care: retrospective study and review of literature

PURPOSE

The purpose is to describe the rate of complications in a series of hip arthroscopies performed at our center, as well as perform a systematic review of the current literature in order to compare our outcomes.

METHODS

Two hundred and fifty-eight patients affected of femoroacetabular impingement and treated with hip arthroscopy have been studied. All minor and major complications were studied during the first postsurgery year. Furthermore, a systematic review was performed comparing major and minor complications with our series. Two attending orthopedic surgeons selected the different studies with the same inclusion and exclusion criteria, remaining with 48 studies that have been reviewed and included in the present study.

RESULTS

Mean age was 36.6 years old (SD 17.45), and the ratio men:women was 137:121. The mean complication rate observed was 14.34% (37/258) of global complications. Only three patients showed major complications: femoral neck fracture, septic arthritis and avascular necrosis of the femoral head. Any of these patients had permanent side effects.

CONCLUSIONS

Hip arthroscopy has a low rate of major complications, but a higher number of minor complications that could be avoided with certain preventive measures.

Clinical Outcomes of Hip Arthroscopic Surgery: A Prospective Survival Analysis of Primary and Revision Surgeries in a Large Mixed Cohort

BACKGROUND

With the rapid increase in hip preservation procedures, revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA) or hip resurfacing (HR) after primary hip arthroscopic surgery have become a large focus in the recent literature.

PURPOSE

The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopic surgery at a high-volume tertiary referral center for hip preservation with a minimum 2-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopic surgery. Patients were assessed preoperatively and postoperatively with the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). Pain was estimated on a visual analog scale (VAS). Patient satisfaction was measured with the question "How satisfied are you with your surgery results?" (1 = not at all, 10 = the best it could be).

RESULTS

There were a total of 1155 arthroscopic procedures performed, including 1040 primary arthroscopic procedures (926 patients) and 115 revision arthroscopic procedures (106 patients). Of these, 931 primary arthroscopic procedures (89.5%) in 824 patients (89.0%) and 107 revision arthroscopic procedures (93.0%) in 97 patients (91.5%) were available for follow-up and included in our study. The mean change in patient-reported outcome (PRO) scores at 2-year follow-up in the primary arthroscopic surgery group was 17.4 for the mHHS, 19.7 for the HOS-ADL, 23.8 for the HOS-SSS, 21.3 for the NAHS, and -3.0 for the VAS, and the mean change in the revision arthroscopic surgery group was 13.4, 10.9, 16.1, 15.4, and -2.7, respectively. All scores improved significantly compared with preoperatively (P < .001). PRO scores were higher at all time points for the primary group compared with the revision group (P < .05). Mean satisfaction was 7.7 and 7.2 for the primary and revision groups, respectively. Of 931 primary arthroscopic procedures, 52 (5.6%) converted to THA/HR. Of 107 revision arthroscopic procedures, 12 (11.2%) converted to THA/HR. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures. The cumulative incidence of competing risks of conversion to THA/HR and revision hip arthroscopic surgery after primary hip arthroscopic surgery was 2.6% and 5.8%, respectively. The overall complication rate was 4.3%.

CONCLUSION

Patients showed significant improvement in all PRO, VAS, and satisfaction scores at 2 years after hip arthroscopic surgery. Patients who underwent primary arthroscopic surgery showed higher PRO scores and a trend toward greater improvement in the VAS score compared with patients who underwent revision arthroscopic surgery. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures.