Simultaneous Versus Staged Bilateral Hip Arthroscopy in the Treatment of Femoroacetabular Impingement

Midterm Outcomes After Simultaneous Hip Arthroscopic Surgery for Bilateral Femoroacetabular Impingement

BACKGROUND

Bilateral hip arthroscopic surgery for the treatment of femoroacetabular impingement (FAI) has demonstrated good outcomes at short-term follow-up, with significant improvements in pain, hip function, and patient-reported outcomes, coupled with a complication rate similar to that of unilateral surgery.

PURPOSE

To investigate whether, in patients with bilateral symptomatic FAI, simultaneous bilateral hip arthroscopic surgery is an efficacious option that produces effective midterm outcomes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A prospective database of patients who underwent primary hip arthroscopic surgery between August 2012 and October 2020 was used to collect clinical data on 2 groups. Group 1 consisted of patients who underwent simultaneous bilateral hip arthroscopic surgery for the treatment of FAI. Group 2 represented a matched-pair control group of patients selected based on sex and age with signs and symptoms of unilateral FAI and in whom a single side was evaluated and treated. Differences in the International Hip Outcome Tool-12 and Non-Arthritic Hip Score scores were evaluated up to 5 years postoperatively.

RESULTS

In total, 171 patients (235 hips) were included, of whom 64 underwent simultaneous bilateral hip arthroscopic surgery (128 hips) and a control group of 107 patients (107 hips) underwent unilateral hip arthroscopic surgery. No significant differences were observed in International Hip Outcome Tool-12 scores between the 2 groups at 6 weeks, 3 months, 1 year, 2 years, and 5 years postoperatively. No significant differences were observed in Non-Arthritic Hip Score scores between the simultaneous bilateral and control groups at 6 weeks, 3 months, 6 months, 1 year, 2 years, and 5 years postoperatively. Overall, 18% of hips in the simultaneous bilateral group reported lateral femoral cutaneous nerve palsy at 2-week follow-up in comparison to 16% of hips in the control group.

CONCLUSION

Simultaneous bilateral hip arthroscopic surgery for the treatment of FAI represents a safe treatment option, producing effective midterm outcomes in appropriately selected patients.

Adhesions After Hip Arthroscopy Are Associated With Revision But Show Poorly Defined Criteria for Diagnosis and Operative Management: A Systematic Review

PURPOSE

To evaluate the current body of evidence surrounding the diagnosis, management, and clinical outcomes of adhesions that developed after hip arthroscopy (HA).

METHODS

A systematic search of the MEDLINE, Embase, Web of Science, and CENTRAL (Cochrane Central Register of Controlled Trials) databases was designed and conducted in accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. Eligible studies included patients with confirmed adhesions after HA that reported one or more of the following: (1) diagnostic procedures and criteria used; (2) indications for and details surrounding surgical management; and (3) clinical outcomes after the operative management of adhesions (e.g., patient-reported outcome measures).

RESULTS

Nineteen studies involving a total of 4,145 patients (4,211 hips; 38% female sex) were included in this review. The quality of evidence was found to be fair for both comparative studies (mean, 17; range, 13-21) and noncomparative studies (mean, 10; range, 5-12) according to the Methodological Index for Non-randomized Studies (MINORS) instrument, with the level of evidence ranging from IIB to IV. Adhesions were often diagnosed intraoperatively at the time of revision surgery (10 of 19 studies, 53%), with only 3 studies specifying the criteria used to adjudicate adhesions. The most common indication for operative management (i.e., release or lysis of adhesions) was persistent pain (9 of 19, 47%), but this was often grossly stated for revision HA rather than being specific to adhesions. Patient-reported outcome measures were the most reported postoperative outcomes (9 of 19, 47%) and generally showed significant improvement from preoperative assessment across the short-term follow-up period (range, 24.5-38.1 months). There was a paucity of objective measures of clinical improvement (3 of 19, 16%) and of mid- and long-term follow-up (i.e., 5-7 years and ≥10 years, respectively).

CONCLUSIONS

Despite the growing body of evidence suggesting that adhesions are highly contributory to revision HA, there is ambiguity in the diagnostic approach and indications for operative management of adhesions. Additionally, although the operative management of adhesions after HA has shown satisfactory clinical outcomes in the short term, there is a paucity of research elucidating the mid- to long-term outcomes, as well as minimal use of objective assessment of clinical improvement (e.g., biomechanics).

LEVEL OF EVIDENCE

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

Accelerated Bilateral Hip Arthroscopy (1 Week Apart): Outcomes Compared With Delayed Bilateral Procedure (4-12 Weeks) and Case-Control Matched Unilateral Arthroscopy

BACKGROUND

Staged bilateral hip arthroscopy is an option for athletes who have symptomatic bilateral femoroacetabular impingement; however, the optimal timing of the second procedure is unknown.

PURPOSE

To evaluate minimum 2-year outcomes for patients undergoing accelerated bilateral arthroscopy against those undergoing (1) delayed bilateral and (2) unilateral arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review was performed of prospectively collected data from patients undergoing bilateral primary hip arthroscopy for femoroacetabular impingement between 2009 and 2022. Inclusion criteria entailed competitive athletes with concurrent bilateral symptoms at initial presentation. Exclusion criteria (either hip) were Tönnis grade >1, dysplasia (lateral center-edge angle <25°), Perthes disease, protrusio acetabuli, and avascular necrosis. Two groups were established based on the duration between procedures: within 7 days (accelerated group) and within 4 to 12 weeks (delayed group). Patients from the accelerated group were matched in a 1:2 ratio with patients undergoing unilateral surgery based on age ±2 years, sex, and athletic status. Minimum 2-year postoperative patient-reported outcomes (PROs) (including modified Harris Hip Score, University of California Los Angeles activity scale, 36-Item Short Form Health Survey, and Western Ontario and McMaster Universities Osteoarthritis Index), rates of achieving the minimal clinically important difference, rates of continuing to play main sport, and satisfaction were compared between groups.

RESULTS

A total of 131 athletes (262 hips) with bilateral femoroacetabular impingement were included: 91 in the accelerated group and 40 in the delayed group. Duration between surgeries was 0.99 ± 0.02 and 6.35 ± 2.18 weeks, respectively. All accelerated athletes were each successfully matched to 2 athletes with unilateral procedures (N = 182). All 3 groups demonstrated significant improvement from baseline across all PROs (P < .001 for all). Acquired change in PROs was similar and not significantly different between groups (P > .05). Satisfaction with relief from pain was achieved by 85.9% of patients in the accelerated group compared with 83.1% in the delayed group (P = .053) and 87.3% in the unilateral group (P = .933). The minimal clinically important difference for the modified Harris Hip Score was achieved by 84.9% of patients in the accelerated group compared with 91.5% in the delayed group (P = .212) and 87.6% in the unilateral group (P = .456). At 2 years postoperatively, the continue-to-play rate was 73.6% for the accelerated group compared with 77.1% for the delayed group (P = .577) and 73.0% for the unilateral group (P = .903). There were no increased complications associated with the accelerated group.

CONCLUSION

Accelerated bilateral hip arthroscopy 1 week apart was a safe and effective treatment option for athletes with bilateral symptoms. Improvement in PROs and continue-to-play rates were comparable with those after a delayed duration between procedures and with those case-control matched athletes undergoing unilateral arthroscopy.

Staging Bilateral Hip Arthroscopies Less Than 1 Year Apart May Reduce the Risk of Revision Surgery

PURPOSE

To identify the influence of timing between staged bilateral hip arthroscopy on 90-day postoperative medical complications and 2-year surgical complications including revision, conversion to total hip arthroplasty (THA), and infection.

METHODS

The Mariner data set of the PearlDiver all-payer claims database was queried for patients undergoing staged bilateral hip arthroscopy. Patients were stratified into cohorts based on time between arthroscopies: (1) ≤3 months, (2) 3 to ≤6 months, (3) 6 to ≤12 months, and (4) >1 year. Multivariate logistic regression was utilized to control for any confounding variables.

RESULTS

In total, 998 patients underwent staged bilateral hip arthroscopy out of 38,080 patients who underwent primary hip arthroscopy. The 2-year revision rate was 7.6% for all patients undergoing bilateral hip arthroscopy, while 1.9% of patients underwent conversion to THA. Patients with arthroscopy procedures staged less than 1 year apart (cohorts 1, 2, and 3) had significantly decreased risk of revision compared to the greater than 1 year cohort (P = .008, .025, and .044, respectively). There were no differences in rates of major medical, minor medical, or remaining surgical complications between the cohorts. Direct comparisons between the cohorts staged ≤1 year apart showed no significant differences in medical or surgical complications (P > .05).

CONCLUSIONS

The revision rate in all patients undergoing staged bilateral hip arthroscopy was 7.6%. Staging hip arthroscopy ≤1 year apart was associated with a decreased risk of revision when compared to the staged cohort >1 year. Among those staged less than 1 year, the timing of staging had no association with rates of medical or surgical complications. Patients who are indicated for bilateral hip arthroscopy may benefit from staging under 1 year apart to reduce the risk of revision surgery. Optimal timing decisions may be patient specific and rely on the duration of symptoms, severity of pathology, or progression of rehabilitation after the index procedure.

LEVEL OF EVIDENCE

III, retrospective comparative study.

Staged Bilateral Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Index Surgery Patient Reported Outcome Measures Predict Contralateral Surgery Results at 2 Years

PURPOSE

To determine whether (1) patient-reported outcome (PRO) scores after index hip arthroscopy correlate with PRO scores for the contralateral hip in patients undergoing staged bilateral hip arthroscopy and (2) patients who achieved minimal clinically important difference (MCID) or patient-acceptable symptom state (PASS) for the index hip were more likely to achieve MCID or PASS for the contralateral hip.

METHODS

Patients who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome were retrospectively reviewed. PRO scores were prospectively collected at preoperative and 1- and 2-year timepoints. Odds ratios for achievement of MCID and PASS for the contralateral hip given achievement for the index hip were calculated. Improvements from before surgery to 2 years after surgery were correlated between both hips.

RESULTS

A total of 143 patients (286 hips) were included in the final analysis. Average time between surgeries was 8.5 months (range, 0.7-57.2). Both hips demonstrated significant improvement (P < .05 for all) in all PROs at 2 years. Achievement of MCID in Hip Outcome Score Activities of Daily Living (HOS-ADL) at the 1-year timepoint for the index hip was predictive of achievement of MCID in HOS-ADL at 2 years for the contralateral hip. Achievement of PASS in all PROs at the 1-year timepoint for the index hip were predictive of achievement of PASS in the equivalent outcome score at the 2-year mark for the contralateral hip. Achievement of MCID or PASS at the 2-year timepoint for the index hip was predictive of achievement of the equivalent outcome at the 2-year timepoint for the contralateral hip. The strongest correlation between improvement in PRO scores for the index and contralateral hips was noted in patients who underwent staged hip arthroscopy within less than 3 months.

CONCLUSION

Patients experience significant clinical benefit in both hips after staged bilateral hip arthroscopy. Results from the initial hip arthroscopy at either 1- or 2-year follow-up can be used to predict outcomes on the contralateral side; however, there is a higher degree of predictive value using 2-year results. Average correlations between 2-year PROs on the index and contralateral hips were moderate to strong, regardless of the time between surgeries.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Outcomes of Staged Bilateral Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome: A Nested Matched-Pair Control Study Focusing on the Effect of Time Between Procedures

BACKGROUND

Bilateral hip symptoms from femoroacetabular impingement syndrome (FAIS) are a common finding in patients regardless of athletic involvement. Oftentimes, patients and surgeons choose to stage bilateral hip arthroscopic surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was (1) to compare minimum 2-year outcomes between patients who underwent staged bilateral hip arthroscopic surgery for FAIS to a propensity score-matched control group that underwent unilateral hip arthroscopic surgery and (2) to investigate the effect of time between bilateral procedures on patient-reported outcomes (PROs). We hypothesized that, after bilateral hip arthroscopic surgery, the improvement in outcomes would be similar to that after unilateral hip arthroscopic surgery and the time duration between bilateral procedures would not affect the final outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively reviewed on a consecutive series of patients who underwent primary hip arthroscopic surgery at our institution between June 2008 and November 2017. Patients who underwent bilateral hip arthroscopic surgery with minimum 2-year PROs for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), patient satisfaction, and a visual analog scale (VAS) for pain were included. The study group was matched 1:1 based on age, sex, and body mass index to a control group that only required unilateral hip arthroscopic surgery. Additionally, a subanalysis was performed on the study group to determine the effect of time between arthroscopic procedures. Rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the mHHS and HOS-SSS were determined. The P value was set at <.05.

RESULTS

A total of 205 patients (410 hips) were included. The mean age and body mass index of the study group were 32.3 ± 13.2 years and 25.0 ± 5.1, respectively. All 410 hips that met the inclusion criteria were matched. There were no significant differences in patient, radiographic, or procedural data. A significant and comparable improvement was reported for all PRO measures and the VAS (P < .0001) in both groups. Similarly, rates of achieving the MCID and PASS were comparable. After dividing the study group based on whether the contralateral procedure was performed <3 months or >3 months after the first procedure, it was determined that patients had a significant improvement and favorable outcomes regardless of time between bilateral procedures.

CONCLUSION

Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAIS had a significant and comparable improvement in PROs at a minimum 2-year follow-up. A time interval of <3 months or >3 months between bilateral procedures did not affect PROs.

Simultaneous bilateral shoulder arthroplasty: a case series

BACKGROUND

Staged bilateral shoulder arthroplasty procedures have been shown to have good functional outcomes. The next step is to explore the option of simultaneous bilateral shoulder arthroplasty (SBSA). We report on the first case series of SBSA in the United States. The purpose of this study was to examine the safety and postoperative complication profile of SBSA and provide a technique reference for surgeons considering performing or investigating this procedure.

METHODS

We conducted a retrospective record review of all the SBSA procedures performed by the senior author between 2007 and 2020. Patient demographic characteristics, surgical information, and postoperative data were collected. Data were compiled, and means, standard deviations, and ranges were calculated. Any readmissions or postoperative complications requiring revision were noted. A cohort of patients matched for age, sex, and body mass index with staged (sequential) bilateral total shoulder arthroplasty was analyzed for comparison.

RESULTS

Thirteen patients were identified in the simultaneous group (SBSA). The mean age was 64 ± 15 years, with 9 women (69%) and 4 men (31%); the mean body mass index was 29.1 ± 7.5. The mean American Society of Anesthesiologists score was 2.55 ± 0.7, average blood loss was 364 ± 170 mL (range, 50-600 mL), 5 of 13 patients (38%) underwent blood transfusions, and the mean surgical time was 183 ± 42 minutes. Postoperatively, the mean visual analog scale pain score on postoperative day 1 was 4 ± 2 (range, 0-7), and the mean length of stay was 3.3 days. Postoperative complications included urinary tract infections in 2 patients, urinary retention in 2 patients, and recurrence of paroxysmal atrial fibrillation in 1 patient. No patient was readmitted within 90 days of surgery. One patient underwent a reoperation 2 years postoperatively for symptomatic hardware removal (cerclage cables around the tuberosities). A matched cohort of staged bilateral total shoulder arthroplasty patients was analyzed for comparison. Postoperative complications in the staged group included 1 reverse total shoulder arthroplasty patient with subjective instability that was managed with additional physical therapy. There were no documented readmissions within 90 days or revision arthroplasty procedures in either cohort.

CONCLUSIONS

SBSA is a reasonable procedure that can be useful in select patients, with promising short-term safety noted in this series. Prospective randomized studies are needed to assess the long-term safety and efficacy of the procedure.

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.

Arthroscopic Management of Femoroacetabular Impingement in Adolescents: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is highly prevalent in adolescent athletes. There has been an increasing trend for arthroscopic surgery for FAI, and the results of several clinical studies on outcome after arthroscopic surgery for FAI are available.

PURPOSE

To conduct a systematic review to investigate the role of arthroscopic management for FAI in adolescents.

STUDY DESIGN

Systematic review.

METHODS

This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In August 2020, PubMed, Scopus, Google Scholar, and EMBASE were accessed. All clinical trials concerning the arthroscopic treatment for adolescents with FAI were identified. Only studies on patients aged less than 18 years at the time of surgery reporting data over a minimum follow-up of 12 months were considered.

RESULTS

Data from 406 adolescents (470 procedures; mean age at surgery, 15.9 years; mean follow-up, 30.4 months) with FAI were retrieved. At a mean of 28.0 months of follow-up, 94% of the adolescents had already returned to sport. All the scores of interest were improved at the final follow-up: visual analog scale (P = .01), modified Harris Hip Score (P < .0001), Non-Arthritic Hip Score (P = .03), Hip Outcome Score-Activities of Daily Living (P = .01), Hip Outcome Score-Sport-Specific Subscale (P < .0001), and Tegner score (P < .0001). Complications occurred in 1.1% (5/470) of procedures, and revision arthroscopy was performed in 4.7% (22/470) of procedures.

CONCLUSION

Arthroscopic surgery in adolescents with FAI achieves excellent outcomes and a high rate of return to sport, with rates of complication and revision surgery of 1% and 5%, respectively.

Use of Younger Patient Age and Greater Anterior Center-Edge Angle to Predict the Need for Bilateral Hip Arthroscopy in Patients With Bilateral Femoroacetabular Impingement-Related Hip Pain

BACKGROUND

In patients with symptomatic femoroacetabular impingement syndrome, bilateral hip pain has been reported to occur in high frequency. However, not all patients require bilateral hip arthroscopy.

PURPOSE

To determine the incidence, patient-specific variables, and postoperative outcomes in patients who presented with bilateral hip pain at the time of index hip arthroscopy and underwent subsequent contralateral arthroscopic hip surgery.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients who presented with bilateral hip pain, underwent primary hip arthroscopy between January 2012 and June 2018 for indication of femoroacetabular impingement syndrome, and had minimum 2-year follow-up were retrospectively analyzed. Baseline descriptive data, preoperative hip range of motion, and radiographic measurements were recorded with pre- and postoperative patient-reported outcomes (PROs). Independent samples t test was used to compare continuous variables, and chi-square test was used to compare categorical variables between patients undergoing unilateral and bilateral surgery. Bivariate correlations and a multivariable binary logistic regression were performed to determine factors predictive of the need for future contralateral hip arthroscopy.

RESULTS

In total, 108 patients were identified who reported bilateral hip pain during the index evaluation, underwent primary hip arthroscopy, and had 2-year follow-up. Among these, 42% (n = 45) elected to undergo hip arthroscopy on the contralateral hip at a mean of 6.0 months (range, 1-17 months) after the index surgery. Patients requiring bilateral surgery were significantly younger (P = .004) and had a larger preoperative anterior center-edge angle (ACEA; P = .038) when compared with patients who had unilateral surgery. There were no significant differences in alpha angle measurements between patients who had unilateral and bilateral surgery. On bivariate analysis, younger age at the time of the index surgery (r = -0.272; P = .005) and preoperative ACEA (r = 0.249; P = .016) were significantly correlated with the need for bilateral surgery. On multivariate analysis, younger age remained a significant predictor for bilateral surgery (odds ratio, 0.95; 95% CI, 0.91-0.99). Patients who underwent bilateral hip arthroscopy reported significant improvement in all PROs (P < .001), with a significantly greater mean Hip Outcome Score- Sports Specific Subscale score when compared with patients undergoing unilateral surgery (P = .037).

CONCLUSION

Subsequent contralateral hip arthroscopy was performed in 42% of patients who presented with bilateral hip pain. Younger age at the time of the index surgery and greater ACEA were predictive of the need for contralateral surgery. Patients undergoing bilateral surgery reported significantly improvement in PROs at minimum 2-year follow-up.

Improvements After Arthroscopic Treatment for Femoroacetabular Impingement Syndrome in High-Level Ice Hockey Players: 2-Year Outcomes by Player Position

Background:

Ice hockey players often undergo arthroscopic treatment for femoroacetabular impingement syndrome (FAIS); however, only a few studies have reported postoperative patient-reported outcomes. It has been debated whether player position is related to FAIS.

Purpose:

To evaluate the change in patient-reported outcome measures (PROMs) in high-level ice hockey players from presurgery to 2 years after arthroscopic treatment for FAIS. The secondary aim was to evaluate differences in outcomes among player positions and whether stick handedness is related to the side of the symptomatic hip.

Study Design:

Case series; Level of evidence, 4.

Methods:

Ice hockey players undergoing treatment for FAIS between 2011 and 2019 were prospectively included. Preoperative and 2-year follow-up scores were collected for the following PROMs: HAGOS (Copenhagen Hip and Groin Outcome Score), iHOT-12 (12-item International Hip Outcome Tool), EQ-5D (EuroQol–5 Dimensions) and EQ-VAS (EuroQol–Visual Analog Scale), Hip Sports Activity Scale, and visual analog scale for overall hip function. Player position and stick handedness were collected from public sources. Preoperative and follow-up outcomes were compared for the entire cohort and among player positions.

Results:

The cohort included 172 ice hockey players with a mean age of 28 years, a mean body mass index of 25.6, and a mean symptom duration of 46.3 months. In the 120 players with 2-year follow-up data, there was significant improvement in all PROMs as compared with presurgery: HAGOS subscales (symptoms, 47.5 vs 68.0; pain, 57.0 vs 75.8; activities of daily living, 62.5 vs 81.0; sports, 40.0 vs 64.7; physical activity, 30.9 vs 57.2; quality of life, 32.5 vs 57.8), iHOT-12 (45.2 vs 66.7), EQ-5D (0.59 vs 0.75), EQ-VAS (68.3 vs 73.2), and visual analog scale for overall hip function (49.6 vs 69.2) (P < .0001 for all). At 2-year follow-up, 83% reported satisfaction with the procedure. There was no difference in the improvement in PROMs among player positions. Further, there was no significant relationship between stick handedness and side of symptomatic hip; however, because of the number of bilateral procedures and large number of left-handed shooters, no conclusions could be drawn.

Conclusion:

High-level ice hockey players undergoing arthroscopic treatment for FAIS reported improvements in PROMs 2 years after surgery, regardless of player position.

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.

Bilateral versus unilateral hip arthroscopy for femoroacetabular impingement: a systematic review

One in four patients presenting with femoroacetabular impingement (FAI) has bilateral symptoms, and despite excellent outcomes reported after arthroscopic treatment of FAI, there remains a paucity of data on the outcomes following bilateral hip arthroscopy. This systematic review aims to examine the outcomes following bilateral (either ‘simultaneous’ or ‘staged’) versus unilateral hip arthroscopy for FAI. A systematic review of multiple electronic databases was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and checklist. All studies comparing simultaneous, staged and/or unilateral hip arthroscopy for FAI were eligible for inclusion. Case series, case reports and reviews were excluded. All study, patient and hip-specific data were extracted and analyzed. The Newcastle–Ottawa Scale was used to assess study quality. A meta-analysis was not performed due to heterogeneity among outcome measures. A total of six studies, including 722 patients (42.8% male) and 933 hips were eligible for inclusion. The mean age across patients was 35.5. The average time between staged procedures was 7.7 months. Four of the six studies were retrospective cohort studies, while the remaining two were prospective in nature. The overall quality of the eligible studies was found to be good. No significant difference was noted among patient-reported outcomes (modified Harris hip score, hip outcome score and non-arthritic hip score), visual analog scale, return to sport, traction time and complications between those undergoing bilateral (simultaneous or staged) versus unilateral hip arthroscopy. Based on the current available evidence, bilateral hip arthroscopy (whether simultaneous or staged) exhibits similar efficacy and safety when compared with unilateral hip arthroscopy. However, further prospective study is required to confirm this finding.

Bilateral Hip Arthroscopy in High-Level Athletes: Results of a Shorter Interval Between Staged Bilateral Hip Arthroscopies

BACKGROUND

Hip arthroscopy is a safe and effective mechanism for treating femoroacetabular impingement symptoms in high level athletes. Bilateral symptoms occur in a subset of this population.

PURPOSE

To discuss outcomes of bilateral hip arthroscopy in high-level athletes and compare a standard staged timeline for bilateral hip arthroscopic surgery versus an accelerated timeline.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of all staged bilateral hip arthroscopies was performed on high-level athletes over a 3-year period. Patients were categorized into cohorts based upon when the second procedure was performed (4-6 weeks after the index procedure or >6 weeks after the index procedure). Exclusion criteria included any prior hip surgery, advanced arthritis, previous pelvic or femoral fracture, or inflammatory arthropathy. Demographics, radiographic measurements, operative reports of procedures performed, and patient-reported outcomes (Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport Specific Subscale, modified Harris Hip Score, return to sports, return to same level of play) were compared between groups at 6-month, 1-year, and 2-year intervals, with the Student t test used for continuous data and a chi-square test used for categorical data.

RESULTS

50 patients were identified: 22 in the accelerated surgery (AS) group and 28 in the standard surgery (SS) group. Age and number of collegiate participants were greater in the AS group, whereas the number of high school participants and the time away from sports were higher in the SS group. Preoperative alpha angles were significantly larger among the AS group, but no differences were found in postoperative alpha angles, center edge angles, or Tönnis grades. No significant difference was seen in patient-reported outcomes between the 2 groups at 6-month, 1-year, and 2-year follow-up.

CONCLUSION

Bilateral hip arthroscopy performed 4 to 6 weeks apart is a safe and effective treatment option for athletes with bilateral femoroacetabular impingement and labral tears; the procedures entail a high rate of return to sports, return to the same level of sports, and decreased time lost from sports. This information could be useful for an athlete deciding on whether to proceed with bilateral hip arthroscopy and deciding on the timing for the procedures.

Physical Activity Following Hip Arthroscopy in Young and Middle-Aged Adults: A Systematic Review

Background

Hip arthroscopy is a common surgical intervention for young and middle-aged adults with hip-related pain and dysfunction, who have high expectations for returning to physical activity following surgery. The purpose of this review was to evaluate the impact of hip arthroscopy on physical activity post-arthroscopy.

Methods

A systematic search of electronic databases was undertaken in identifying studies from January 1st 1990 to December 5th 2019. The search included English language articles reporting physical activity as an outcome following hip arthroscopy in adults aged 18-50 years. Quality assessment, data extraction and synthesis of included studies were undertaken.

Results

Full text articles (n = 234) were assessed for eligibility following screening of titles and abstracts (n = 2086), yielding 120 studies for inclusion. The majority (86%) of the studies were level 4 evidence. One study reported objective activity data. The most frequently occurring patient-reported outcome measure was the Hip Outcome Score-sport-specific subscale (HOS-SS, 84% of studies). Post--arthroscopy improvement was indicated by large effect sizes for patient-reported outcome measures (standard paired difference [95% confidence interval] −1.35[−1.61 to −1.09] at more than 2 years post-arthroscopy); however, the majority of outcome scores for the HOS-SS did not meet the defined level for a patient-acceptable symptom state.

Conclusion

The current level of available information regarding physical activity for post arthroscopy patients is limited in scope. Outcomes have focused on patients’ perceived difficulties with sport-related activities with a paucity of information on the type, quality and quantity of activity undertaken.

Level of Evidence

Level IV, systematic review of Level 2 through to Level 4 studies

Metabolic and Hemodynamic Results and Early Complications in Simultaneous Bilateral versus Unilateral Hip Arthroscopy

Background

To compare the hemodynamic parameters—electrolyte concentration, D-dimer level, creatine phosphokinase level—and the incidence of early complications of simultaneous bilateral versus unilateral hip arthroscopy.

Methods

A prospective study was conducted on patients (> 18 years of age) undergoing unilateral or bilateral hip arthroscopy under the same anesthetic between 2013 and 2015. Patients were followed up for 30 days after surgery. In all cases, data were collected before, during, and after the surgical procedure.

Results

One hundred cases of hip arthroscopy (51 unilateral and 49 bilateral) were included in this study. There was a greater variation in systolic blood pressure and heart rate in the unilateral group. The sodium levels were higher in the bilateral group with an adjusted mean difference of 5.31 mmol/L (p < 0.001). During the first 24 hours after the procedure, the proportion of patients with an altered D-dimer of > 500 ng/mL was 85.7% in the bilateral group and 56.9% in the unilateral group. There was no significant difference in the incidence of complications between the groups (bilateral, 8.2%; unilateral, 9.8%; crude odds ratio, 0.83; 95% confidence interval, 0.24 to 2.92; p = 0.526).

Conclusions

The variations of hemodynamic parameters in patients undergoing hip arthroscopy remained within normal ranges. The findings of this study suggest that bilateral hip arthroscopy be selected according to the patient's condition, considering that the risk of complications and metabolic alterations in bilateral hip arthroplasty are similar to those in unilateral arthroscopy.

Bilateral Hip Arthroscopy: Can Results From Initial Arthroscopy for Femoroacetabular Impingement Predict Future Contralateral Results?

PURPOSE

To determine the degree of correlation of radiographic measurements, degree of correlation of intraoperative pathology, and difference in outcomes between sides of patients requiring staged bilateral hip arthroscopy.

METHODS

Two high-volume hip preservation centers retrospectively reviewed hip preservation databases for staged bilateral hip arthroscopies conducted between 2008 and 2015. Patients were separated into those who presented with bilateral hip pain and those that presented with unilateral pain and developed contralateral pain >2 years later. Patients were analyzed for radiographic correlation (alpha angle, lateral center edge angle, anterior center edge angle, magnetic resonance imaging alpha angle, Tönnis grade) and correlation of intraoperative pathology (acetabular labrum articular disruption grade, Outerbridge grade/location, Villar class ligamentum teres tears, labral tear location, symmetry of Seldes tear types, and the differences between operative procedures). Patient-reported outcomes were analyzed (modified Harris Hip Score, Non-Arthritic Hip Score, International Hip Outcome Tool-12, hip outcome score-sport specific subscale, visual analog scale, patient satisfaction). Correlative tests included Pearson and Spearman; univariate and multivariate analysis for differences included χ-square test and Student t tests for ordinal and continuous variables respectively.

RESULTS

A total of 133 of 2,705 patients (4.6%) underwent bilateral hip arthroscopy. Radiographic alpha angle, magnetic resonance imaging alpha angle, lateral center edge angle, and anterior center edge angle demonstrated strong correlation (Pearson's coefficients 0.651, 0.648, 0.644, 0.667, respectively, P < .0001). Tönnis grade was weakly correlated (Pearson's coefficient 0.286, P = .001). Intraoperative pathology was moderately correlated (Pearson's coefficients for acetabular Outerbridge location, 0.300, P = .0170; acetabular labrum articular disruption, 0.490, P < .0001; acetabular Outerbridge; 0.530; P < .0001; femoral head Outerbridge, 0.459, P < .0001; Villar class, 0.393, P < .0001; and labral tear location, 0.468, P < .0001). Labral tear Seldes type was compared with Bowker's symmetry test and there was no significant difference between sides. There were no significant differences in surgical interventions performed between sides. Patients with bilateral hip arthroscopies significantly improved in all measured patient-reported outcomes and had a high patient satisfaction after both procedures. Final patient-reported outcomes and change in patient-reported outcomes were not different between procedures; follow up ranged from 3 months to 8 years.

CONCLUSIONS

This study demonstrated an incidence of 4.6% of patients who require bilateral hip arthroscopy. These patients can expect significant improvement after surgical intervention. Patients that had 1 side done gained similar improvement when the contralateral side was performed. Preoperative radiographic, intraoperative pathology, and procedures performed were similar between hips.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Editorial Commentary: Doctor, Will My Contralateral Hip Surgery Go as Well as the First One?

Patients presenting with bilateral symptomatic femoroacetabular impingement for staged bilateral hip surgery or developing pain in their nonoperated hip after hip arthroscopy are likely to have similar pathology in both hips. They have a high likelihood of similarly good outcome after their contralateral hip arthroscopy.

Simultaneous Bilateral Hip Arthroscopy in Adolescent Athletes With Symptomatic Femoroacetabular Impingement

BACKGROUND

Femoroacetabular impingement represents a common cause of hip pain in adolescents. The purpose of the present study was to evaluate the safety and efficacy of simultaneous bilateral hip arthroscopy for bilateral symptomatic femoroacetabular impingement in adolescent athletes.

METHODS

Clinical data were collected in a prospective database on patients who underwent unilateral or simultaneous bilateral hip arthroscopy and included complications, reoperation rate, and return to play time. Differences in International Hip Outcome Tool (iHOT)-12 scores according to hip side and postoperative follow-up time (preoperative, 1.5, 3, 6, 12, and 24 mo) were evaluated using a 2×6 repeated-measures analysis of variance with post hoc repeated-measures 1-way analysis of variance and Bonferroni-corrected paired t tests.

RESULTS

In total, 24 patients (36 hips) were studied, of whom 12 underwent simultaneous bilateral hip arthroscopy (24 hips) and a case-matched control group of 12 patients underwent unilateral hip arthroscopy. There were 5 males in each group (41.7%). Average age was 15.7 and 16.5 years in the bilateral and unilateral groups, respectively. No patients were lost to follow-up. In the bilateral group, a significant increase in mean iHOT-12 score was observed between 1.5- and 3-month follow-up (61.8 vs. 82.8, respectively; P=0.003), and 6-, 12-, and 24-month follow-up (91.4, 95.1, and 96.6, respectively, P=0.004). At all follow-up times, there were no significant differences in mean iHOT-12 scores or other outcome measures between bilateral and unilateral cohorts. Time to return to preinjury level of activity was similar between the bilateral and unilateral groups (4.7 vs. 4.9 mo, respectively; P=0.40). One transient lateral femoral cutaneous nerve palsy occurred in each group, though no other complications were documented. No patients required revision surgery by latest follow-up.

CONCLUSIONS

Bilateral simultaneous hip arthroscopy is safe and reproducible in adolescent athletes, achieving equivalent outcomes, and similar rehabilitation time when compared with unilateral surgery.

LEVEL OF EVIDENCE

Level II-therapeutic study.

Risk Factors for Bilateral Femoroacetabular Impingement Syndrome Requiring Surgery

Purpose:

To identify the risk factors for contralateral surgery in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

Methods:

Patients who underwent unilateral surgery were compared with those who underwent staged bilateral surgery to identify risk factors associated with bilateral surgery. Variables examined included demographics, comorbidities, and radiographic features. Binary logistic regression was used to identify predictors of bilateral FAIS.

Results:

A total of 694 patients with an average age of 34.0 ± 13.1 years met were included in the analysis. Overall, 109 patients (15.3%) had staged bilateral hip arthroscopy for FAIS. Risk factors associated for bilateral FAIS requiring surgery were decreased age and lower Charlson Comorbidity Index (CCI). Compared with patients aged <25 years, those aged 25 to 34 years (odds ratio [OR], 0.5; P = 0.031), 35 to 44 years (OR, 0.5; P = 0.034), and ≥45 years (OR, 0.3; P = 0.002) had lower odds of bilateral labral tear. In addition, patients with a CCI <2 were three times more likely to require bilateral FAIS surgery (OR, 3.4; P = 0.044). None of the radiographic parameters predicted bilateral labral tears.

Conclusion:

Patients younger than 25 years and those with a CCI <2 had markedly increased rates of bilateral FAIS necessitating surgery compared with older patients. This study may be of value in preoperative counseling.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

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

Consecutive Bilateral Hip Arthroscopy for Symptomatic Bilateral Femoroacetabular Impingement in an Elite Rugby player: A Case Report

We report a case of concurrent bilateral hip arthroscopy for symptomatic bilateral femoroacetabular impingement (FAI) performed under the single anesthesia on an elite rugby player. A 27-year-old rugby player who played for a top league had bilateral hip joint pain. Physical examination revealed bilateral tenderness in the anterior area of the hips, with positive impingement signs. Based on the findings of hip radiography and magnetic resonance imaging, the patient's symptoms were diagnosed as bilateral FAI with hip labral tears. Bilateral hip arthroscopy under the single anesthesia was performed due to refractory symptoms. He returned to regular rugby games without any symptoms in either hip. Bilateral hip arthroscopic surgery under the single anesthesia should be an effective treatment for typical and symptomatic FAI, even in elite athletes.

A Comparison of Clinical Outcomes After Unilateral or Bilateral Hip Arthroscopic Surgery: Age- and Sex-Matched Cohort Study

BACKGROUND

A significant number of patients undergoing hip arthroscopic surgery for femoroacetabular impingement (FAI) have bilateral deformities and may require surgery for both hips.

PURPOSE

To compare outcomes between patients who underwent bilateral hip arthroscopic surgery to a matched cohort of patients who underwent unilateral hip arthroscopic surgery.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A consecutive series of patients who underwent primary hip arthroscopic surgery for FAI by a single fellowship-trained surgeon from January 2012 to January 2014 and had a minimum follow-up of 2 years were evaluated. Patients who underwent staged bilateral hip arthroscopic surgery were identified and matched 1:2 to patients who underwent unilateral hip arthroscopic surgery based on age, sex, and body mass index (BMI). Demographic, preoperative, and postoperative variables were compared between the groups.

RESULTS

Forty-three patients in the bilateral group were matched with 86 patients in the unilateral group based on sex (24 female [56%] vs 48 female [56%], respectively; P > .99), age (28.6 ± 10.8 years vs 28.9 ± 10.8 years, respectively; P = .88), and BMI (24.8 ± 5.8 kg/m² vs 24.8 ± 4.0 kg/m², respectively; P = .98). There were no significant preoperative demographic or radiographic differences between the groups. Both groups demonstrated significant preoperative to postoperative improvements in the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Subscale (HOS-SS), and modified Harris Hip Score (mHHS) ( P < .0001 for all). When compared with patients in the unilateral group, patients who underwent bilateral hip arthroscopic surgery had less improvement in mHHS and pain scores. Sixty-five (76%) patients in the unilateral group achieved the minimum clinically important difference (MCID) for the mHHS compared with 21 (49%) in the bilateral group ( P = .03), while 64 (74%) patients achieved the patient acceptable symptomatic state (PASS) for the mHHS compared with 22 (51%) in the bilateral group ( P = .02). Patients in the bilateral group with greater than 10 months between surgical procedures had lower postoperative HOS-ADL scores ( P = .04) and lower improvement in pain and HOS-SS scores ( P < .0001 and P = .05, respectively).

CONCLUSION

Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAI had improved functional outcomes after 2 years. However, patients who underwent bilateral hip arthroscopic surgery had less improvement in their mHHS and pain scores compared with those who underwent unilateral hip arthroscopic surgery but no differences in HOS-ADL, HOS-SS, or satisfaction scores. Patients in the bilateral group with longer than 10 months between surgical procedures had lower outcome scores than patients who underwent their second surgical procedure within 10 months of their primary surgery.

Simultaneous Bilateral Hip Arthroscopy

Many patients are afflicted with painful conditions affecting both hips, most commonly femoroacetabular impingement. Some patients prefer the advantage of undergoing a single surgical procedure and anesthetic followed by a single postoperative rehabilitation program. We present a Technical Note on single-stage bilateral hip arthroscopy. This Technical Note reports on key steps enabling safe and efficient performance of bilateral arthroscopic acetabuloplasty, labral refixation, femoroplasty, and dynamic testing while limiting traction times and facilitating rapid transition to the second hip arthroscopic surgery. Enabling factors include supine positioning with bilateral mobile leg spars, rapid surgical and hip traction times, and postoperative rehabilitation with immediate weight bearing as tolerated. A rationale for deciding which hip should undergo arthroscopy first is also offered. Concurrent bilateral hip arthroscopy is a viable option for select patients and experienced surgical teams, enabling potentially expedited recovery and return to work or sport with inherent cost savings.

Editorial Commentary: Hip Capsule: To Repair or Not?

Arthroscopic hip capsular repair is an area of intense interest. Basic science studies suggest that adverse changes in capsular stability/restraint may occur with capsulotomy and capsulectomy, that repair may ameliorate these changes, and, most recently, that the repaired capsule usually heals. Clinical studies suggest that in some conditions, most notably mild dysplasia, capsular repair or plication may improve short-term outcomes, but in general, the role of capsular closure is less clear. At present, perhaps a selective approach is merited, with capsular closure performed in patients with dysplasia, focal or generalized hyperlaxity, and/or increased femoral anteversion. The comparative outcomes from smaller, more vertically oriented capsulotomies with less violation of the iliofemoral ligament deserve investigation.

Editorial Commentary: Shall We Just Get It All Done With? Simultaneous Versus Staged Bilateral Hip Arthroscopy

Simultaneous bilateral hip arthroscopies have comparable patient-reported outcomes and little risk of complications when compared with staged bilateral hip arthroscopies in the treatment of femoroacetabular impingement. There will always be a selection bias, however: rehabilitation requiring 4-point gait will be more difficult, and some would consider that a simultaneous bilateral operation is more suited for the young, motivated, physically fit patient.