Defining Meaningful Functional Improvement on the Visual Analog Scale for Satisfaction at 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Association of Patient Satisfaction 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome With Minimum 10-Year Patient-Reported Outcomes and Survivorship

BACKGROUND

Previous studies have shown that short-term outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) predict midterm outcomes, but a limited number of studies have evaluated whether short-term outcomes predict long-term outcomes and survivorship.

PURPOSE

To evaluate whether achieving clinically significant outcomes at 2 years after hip arthroscopy for FAIS can predict patient-reported outcomes (PROs) and survivorship at 10 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopy for FAIS between June 2012 and December 2012 with a minimum 10-year follow-up were identified. Using previously established thresholds, we classified patients who achieved the 2-year Patient Acceptable Symptom State (PASS) for the visual analog scale (VAS) for satisfaction as the high satisfaction group and patients who did not as the low satisfaction group. Minimum 10-year PROs were then compared between the groups, including scores for the Hip Outcome Score (HOS)-Activities of Daily Living and -Sports Specific, the modified Harris Hip Score, the VAS for pain, and the VAS for satisfaction. Reoperation-free survivorship was compared.

RESULTS

Of 120 eligible consecutive patients, 85 patients were included (70.8% follow-up rate), of whom 61.2% were female. The mean age was 34.0 ± 12.8 years, and the mean body mass index was 25.4 ± 4.6. Of the 85 patients, 29 (34.1%) did not achieve PASS for the VAS for satisfaction at 2 years postoperatively compared with 56 (65.9%) who did. The low satisfaction group had significantly worse acetabular chondral grades at the time of surgery (P = .008). At minimum 10-year follow-up, the high satisfaction group showed significantly better HOS-Activities of Daily Living, HOS-Sports Specific, modified Harris Hip Score, VAS pain, and VAS satisfaction scores (P≤ .031). Compared with the low satisfaction group, the high satisfaction group had a significantly lower rate of secondary surgery (1.8% vs 24.1%, respectively; P = .002).

CONCLUSION

Patients who achieved PASS for the VAS for satisfaction at 2 years after hip arthroscopy demonstrated superior minimum 10-year outcomes compared with patients who did not, including greater PRO scores and a higher survivorship rate. The high satisfaction group had lower grade acetabular cartilage damage at the time of surgery compared with those who did not achieve PASS for the VAS for satisfaction at 2 years.

Hip Arthroscopy Patients With Lower Back Pain Show Delayed Clinical Improvement and Inferior Time-Dependent Survivorship: A Propensity Matched Study at Mid-Term Follow-Up

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at mid-term follow-up after hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) in patients with and without preoperative lower back pain (LBP).

METHODS

Patients with self-endorsed preoperative LBP who underwent HA for FAIS with mid-term follow-up were identified and propensity matched 1:1 to patients without back pain by age, sex, and body mass index (BMI). PROs collected preoperatively and at postoperative years 1, 2, and 5 included Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Hip Outcome Score-Sports Subscale (HOS-SS), 12-item International Hip Outcome Tool (iHOT-12), modified Harris Hip Score (mHHS), and Visual Analog Scale (VAS) for Pain. Achievement of minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were compared. Survivorship was compared with Kaplan-Meier analysis.

RESULTS

In total, 119 patients with LBP were matched to 119 patients without LBP. Group demographic factors were as follows: age (37.4 ± 11.9 vs 37.6 ± 12.6 years, P = .880), sex (64.4% vs 67.7% female, P = .796), and BMI (25.3 ± 5.1 vs 25.3 ± 5.4, P = .930). Average follow-up duration was 6.0 ± 1.9 years. LBP patients showed similar preoperative PROs, yet lower 1-year scores for all PROs (P ≤ .044). At final follow-up, similar PROs were shown between groups (P ≥ .196). LBP and non-LBP patients had similar MCID achievement for HOS-ADL (59.3% vs 63.1%, P = .640), HOS-SS (73.9% vs 70.8%, P = .710), mHHS (66.7% vs 73.4%, P = .544), iHOT-12 (85.1% vs 79.4%, P = .500), and VAS Pain (75.6% vs 69.9%, P = .490). Groups also had similar PASS achievement for HOS-ADL (63.5% vs 61.3%, P = .777), HOS-SS (57.0% vs 62.5%, P = .461), mHHS (81.9% vs 79.1%, P = .692), iHOT-12 (54.6% vs 61.2%, P = .570), and VAS Pain (51.0% vs 55.4%, P = .570). Additionally, achievement of MCID ≥ 1 PRO (P ≥ .490) and PASS ≥ 1 PRO (P ≥ .370) was similar across groups. Conversion to total hip arthroplasty occurred in 3.4% of hips with LBP and 0.8% of hips without LBP (P = .370). Back pain patients demonstrated inferior time-dependent survivorship compared with patients without back pain on Kaplan-Meier survival analysis (P = .023).

CONCLUSIONS

Patients undergoing primary hip arthroscopy for FAIS with LBP achieve comparable PROs and clinically significant outcomes to patients without back pain at mid-term, despite lower 1-year PRO scores. LBP patients show inferior reoperation-free time-dependent survivorship compared with those without LBP.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Effect of age and gender in rates of achieving minimal clinically important difference and patient-acceptable symptom state 2 years after arthroscopic superior capsular reconstruction

PURPOSE

This study aimed to evaluate patient-reported outcome measures (PROMs) and the effects of gender and age on achieving clinically significant outcomes in patients undergoing arthroscopic superior capsular reconstruction (ASCR) with a minimum 2-year follow-up.

METHODS

Patients undergoing ASCR for irreparable rotator cuff tear between 2013 and 2020 were reviewed. Preoperative and minimum 2-year postoperative PROMs were collected, including American Shoulder and Elbow Surgeons (ASES), Constant, single assessment numeric evaluation (SANE), and visual analog scale (VAS) scores. Minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) were calculated for each functional score and analyzed according to age and gender. The percentages of patients achieving MCID and PASS were recorded.

RESULTS

The study included 83 patients, with a mean follow-up of 3.5 ± 1.4 years. Significant improvements were found in ASES, Constant, SANE, and VAS for all groups based on gender and age. Based on receiver-operating characteristic curves, all scores had acceptable areas under the curve for PASS. Values for PASS and MCID were 81.5 and 10.3 for ASES; 61.5 and 6.2 for Constant; 82.5 and 11.5 for SANE and 1.5 and 1.1 for VAS, respectively. Analysis of achieving MCID and PASS showed no difference between the groups in the majority of outcome measures. However, female patients achieved the SANE thresholds for PASS at significantly higher rates than male patients. Patients ≥65 years old achieved ASES and Constant thresholds for MCID at significantly higher rates than patients ˂65 years old.

CONCLUSION

Most patients achieved MCID and PASS at a 2-year follow-up. Patients showed comparable rates of MCID and PASS achievement on most outcome tools based on age and gender. Female patients achieved PASS on SANE at significantly higher rates than male patients and older patients achieved MCID on ASES and Constant at higher rates than young patients. Thus, age is a stronger factor for achieving MCID than gender.

LEVEL OF EVIDENCE

Level II.

Intermediate-Term Outcomes of Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Patients With Global Versus Isolated Lateral Acetabular Overcoverage

BACKGROUND

Previous studies evaluating the outcomes of hip arthroscopy for patients with global acetabular overcoverage and focal superolateral acetabular overcoverage suffer from short-term follow-up and inconsistent radiographic criteria when defining these subpopulations of patients with femoroacetabular impingement syndrome (FAIS).

PURPOSE

To evaluate the intermediate-term postoperative outcomes for patients with FAIS in the setting of global acetabular overcoverage, lateral acetabular overcoverage, and normal acetabular coverage.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for FAIS were enrolled in a prospective cohort study, and those with a minimum follow-up of 5 years were included in this analysis. Patients were grouped based on type of acetabular coverage: global overcoverage (lateral center-edge angle [LCEA] ≥40°, with coxa profunda), lateral overcoverage (LCEA ≥40°, without coxa profunda), and no overcoverage (LCEA <40°). Functional outcomes (modified Harris Hip Score and Nonarthritic Hip Score) and failure of primary hip arthroscopy were compared between groups.

RESULTS

In total, 94 patients (mean age, 41.9 ± 14.2 years) were included with a mean follow-up duration of 6.1 ± 0.9 years. Of these patients, 40.4% had no acetabular overcoverage, 36.2% had lateral overcoverage, and 23.4% had global overcoverage. There was no difference between groups with respect to percentage of patients who underwent reoperation for either revision arthroscopy or conversion to total hip arthroplasty (28.9% for the normal acetabular coverage group, 29.4% for the lateral overcoverage group, and 31.8% for the global overcoverage group; P = .971). Among patients for whom primary hip arthroscopy did not fail, there was no difference in 5-year functional outcomes between groups. Postoperative LCEA >40° (β = -13.3; 95% CI, -24.1 to -2.6; P = .016), female sex (β = -14.5; 95% CI, -22.7 to -6.2; P = .001), and higher body mass index (β = -1.9; 95% CI, -2.8 to -1.0; P < .001) were associated with worse intermediate-term hip function in terms of modified Harris Hip Score.

CONCLUSION

There was no difference in functional outcomes or rate of reoperation at a minimum of 5 years postoperatively between those with global acetabular overcoverage, those with regional lateral overcoverage, and those with normal acetabular coverage. Provided that an appropriate acetabuloplasty is performed, there is no evidence to suggest that global acetabular overcoverage portends a worse prognosis than other FAIS subtypes.

The Relationship Between Patient-Reported Outcomes and Patient Satisfaction With Ligament Reconstruction Tendon Interposition

PURPOSE

Achieving the minimal clinically important difference (MCID) on an outcomes instrument and reporting satisfaction with surgical outcomes are not equivalent. We hypothesized that improvement exceeding the QuickDASH and PROMIS UE CAT MCID is associated with a greater likelihood of reporting satisfaction with ligament reconstruction tendon interposition (LRTI) treatment. Our secondary hypothesis was that a subset of patients failing to meet MCID would still be satisfied.

METHODS

Patients ≥1 year after LRTI at one academic tertiary institution were included. QuickDASH and UE CAT v1.2 scores were obtained before and after surgery. Postoperative satisfaction and levels of improvement in pain and function were also obtained.

RESULTS

A total of 93 patients completed the QuickDASH, and of those, 90 also completed the UE CAT. At a mean of 2.6 ± 1.0 years after surgery, QuickDASH and UE CAT score improvement exceeded the previously published MCID estimates of 8.8 and 4.8. Although 90% (84/93) of the patients reported satisfaction, only 85% (72/93) and 72% (59/90) achieved MCID on the QuickDASH and UE CAT, respectively. Using the MCID estimate of 8.8, 96% (72/75) of the patients meeting the MCID were satisfied with their treatment. Those failing to achieve MCID reported significantly less physical function and pain improvement; however, most were satisfied nonetheless (68% [13/19] for QuickDASH, 77% [23/30] for UE CAT).

CONCLUSIONS

Achieving published MCID thresholds on the QuickDASH and PROMIS UE CAT v1.2 was predictive of patients reporting general satisfaction with their LRTI outcome ≥1 year after surgery. Most patients failing to achieve MCID still reported satisfaction with their LRTI. Achieving MCID thresholds alone should not be used as a surrogate for patient satisfaction with their treatment. Patient satisfaction is a complicated construct that is potentially very different from that of high-quality care.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Use and Effectiveness of Physical Therapy After Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Limited literature exists regarding how postoperative physical therapy (PT) may affect outcomes in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. Additionally, it is unknown how PT measures relate to traditional orthopaedic patient-reported outcomes (PROs).

PURPOSE

To evaluate how the duration of PT may correlate with outcomes in patients with FAIS using both the Lower Extremity Functional Scale (LEFS) and standard orthopaedic PRO measures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients from a single institution who underwent primary hip arthroscopy for FAIS between 2013 and 2016 were identified. Patients with a minimum 2-year follow-up and fully documented PT notes were included and stratified into 3 cohorts based on timing of PT discharge: 0 to 3 months, 3 to 6 months, and 6 to 12 months. Predictive regression models were developed to analyze the rate of improvement (ROI) in LEFS score as it relates to (1) postoperative day (POD) and (2) postoperative PT session number. Two-year PROs were collected, correlated with LEFS scores, and compared among cohorts.

RESULTS

A total of 95 patients were included (mean ± SD age, 34.6 ± 11.7 years; range, 14-55 years). Mean LEFS scores increased significantly from the initial score at 6 weeks, 3 months, and the time of PT discharge (P < .01 for all). The predicted ROI in LEFS score was 3.39% per PT session for sessions 0 to 13, 1.43% for sessions 14 to 27, and 0.37% for sessions 28 to 40. Patients who underwent 3 to 6 months of PT had significantly better Hip Outcome Score (HOS) relative to the 0- to 3-month cohort and significantly better visual analog scale (VAS) scores for satisfaction relative to the 6- to 12-month cohort. The predicted ROI in LEFS score was 0.96% per day from POD 0 to 45, 0.22% from POD 46 to 139, and 0.03% after POD 139. Moderate correlations were seen between LEFS score at the time of discharge and all 2-year PROs as follows: HOS Activities of Daily Living subscale (r = 0.488), HOS Sports-Specific subscale (r = 0.500), modified Harris Hip Score (r = 0.465), 12-item International Hip Outcome Tool (r = 0.494), VAS pain score (r = -0.346), and VAS satisfaction score (r = 0.459).

CONCLUSION

Patients undergoing hip arthroscopy for FAIS derived substantial benefit from each PT visit during their first 13 PT sessions and then a smaller, yet still meaningful benefit from sessions 13 through 27. After session 40, or approximately 4.5 to 5 months, patients no longer benefited from additional PT sessions. Based on PRO scores, patients discharged from PT between 3 and 6 months had the best 2-year outcomes. LEFS score had moderate correlation with orthopaedic PRO scores.

Relationship between the Depth of Acetabuloplasty and Outcomes of Hip Arthroscopy in Patients with Global Pincer Femoroacetabular Impingement: Study with a Minimum Follow-Up Period of 2 Years

OBJECTIVE

There has been no definite consensus on the ideal depth of acetabuloplasty, especially in cases of global pincer femoroacetabular impingement (FAI). This study aims to determine whether the depth of acetabuloplasty influences postoperative outcomes in cases of global pincer FAI.

METHODS

Data were retrospectively collected from patients with global pincer FAI who underwent hip arthroscopy with a minimum follow-up period of 2 years from May 2014 to December 2018. Patients with global pincer FAI were subdivided into low or high resection depth groups based on whether the intraoperative acetabular rim was resected by more than 3 mm. Radiographic measurements; arthroscopic procedures; preoperative and postoperative PROs were recorded. Achievement of MCID and PASS was compared for the VAS, mHHS, HOS-ADL, and iHOT-12. A paired Student t-test was used to evaluate the significance of preoperative and postoperative PROs and two-tailed unpaired Student t-test was used to compare demographic data and PROs between different groups. MCID and PASS were evaluated using the chi-square test or the Fisher's exact test.

RESULTS

A total of 41 hips with global pincer FAI (15 and 26 patients in low or high resection depth groups, respectively) were included in this study. Both groups showed significant postoperative improvements in the scores of all PROs (p < 0.001). Compared to the low resection depth group, the high resection depth group had a lower degree of improvement through hip arthroscopy, which manifested as lower postoperative mHHS scores (94.29 vs. 85.08, p = 0.006), higher VAS scores (0.93 vs. 2.54, p = 0.002), and lower improvements in VAS (-5.00 vs. -3.35, p = 0.028), HOS-ADL (34.99 vs. 23.90, p = 0.017) and iHOT-12 (39.89 vs. 29.27, p = 0.036). Patients in high resection depth group were less likely to achieve the MCID for the VAS score compared to low resection depth group in significant (73.3 vs. 26.9%, p = 0.004).

CONCLUSIONS

For patients with global pincer, the outcomes in high resection depth group were slightly worse than the the low resection depth group. It is indicated that excessive resection of the acetabular rim during the procedure should be avoided.

Effects of spinal stabilization exercises delivered using telerehabilitation on outcomes in patients with chronic neck pain: a randomized controlled trial

BACKGROUND

When spinal stabilization exercises (SSE) are performed regularly, may provide benefits on outcome measures in chronic nonspecific neck pain (CNNP) patients. The pandemic has made it difficult for CNNP patients to access regular physiotherapy-exercise services. This study aims to compare telerehabilitation (TR) with face-to-face rehabilitation in CNNP.

METHODS

Neck Functional Capacity Evaluation Test (NFCET) results were the primary outcomes. Pain intensity (PI), disability, awareness, neck muscles architecture, andexercise satisfaction were the secondary outcomes. Patients were randomized into the TR group (TRG) (n = 15) and the control group (CG) (n = 16). Patients performed SSE 3 days a week, for 8 weeks. The TRG was instructed remotely while the CG was instructed in the clinic.

RESULTS

After 8 weeks in both groups, NFCET values and neck awareness increased (p < 0.05), PI and disability decreased (p < 0.05).      Muscle architecture improved in both groups (p < 0.05), except for the Right Sternocleidomastoideus in both groups and the Right Upper-Trapezius in TRG (p > 0.05). There was no difference between the groups for all variables and exercise satisfaction(p > 0.05).

CONCLUSION

SSE for CNNP, whether supervised by therapists in the clinic or by telerehabilitation, was equally effective.

THE CLINICAL TRIAL NUMBER

NCT04691024.

Outcomes in Patients with Global Pincer Versus Focal Pincer Femoroacetabular Impingement Treated with Hip Arthroscopy: A Retrospective Study with a Minimum 2-Year Follow-Up

OBJECTIVE

Global pincer is a relatively rare form of pincer deformity and is typically associated with technical challenges during surgery. So far, controversy remains whether patients with global pincer have equivalent surgical outcomes compared to patients with focal pincer. This study compares the clinical outcomes of arthroscopic treatment between patients with global pincer femoroacetabular impingement (FAI) and focal pincer FAI in the Chinese population.

METHODS

Data were retrospectively collected from patients with global and focal pincer FAI who underwent hip arthroscopy with a minimum two-year follow-up between April 2016 and December 2018. Radiographic measurements, arthroscopic procedures, preoperative and postoperative patient-reported outcomes (PROs) including modified Harris hip score (mHHS), hip outcome score-activities of daily living (HOS-ADL), international hip outcome tool-12 (iHOT-12), and visual analogue scale (VAS) scores, rates of revision surgery and conversion to total hip arthroplasty (THA) were recorded. Achievement of minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) was compared for the VAS, mHHS, HOS-ADL, and iHOT-12 scores between groups.

RESULTS

The total of 33 and 167 patients were included in the global and focal group, respectively. There were no intergroup differences in age, gender, body mass index or follow-up times. Lateral center-edge angle (LCEA) was reduced in both groups postoperatively. Both groups demonstrated significant improvements in PROs compared with preoperative levels at the final follow-up. The preoperative scores showed significant differences in terms of mHHS (60.34 vs 62.90, P = 0.031) and HOS-ADL (61.45 vs 64.74, P = 0.022) scores between two groups, and the improvement of HOS-ADL score was significantly higher in global group (P = 0.027). However, the postoperative scores, including VAS, mHHS, HOS-ADL, and iHOT-12 scores, showed no significant differences between two groups. And there were no significant differences in the rate of meeting the PASS and MCID between groups. One (3.0%) in the global group and six (3.6%) patients in the focal group underwent revision arthroscopy respectively, with no significant difference (P = 0.876). There were no conversions to THA in both groups.

CONCLUSIONS

Arthroscopic management of global pincer FAI can achieve excellent functional scores at minimum 2-year follow-up. The outcomes were similar to focal pincer FAI patients with a low rate of secondary procedure.

Criteria for Return to Play After Hip Arthroscopy in the Treatment of Femoroacetabular Impingement: A Systematic Review

BACKGROUND

Femoroacetabular impingement (FAI) is a common pathology in athletes that often requires operative management in the form of hip arthroscopy.

PURPOSE

To systematically review the rates and level of return to play (RTP) and the criteria used for RTP after hip arthroscopy for FAI in athletes.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of the literature, based on the PRISMA guidelines, was performed using PubMed, Embase, and Scopus databases. Studies reporting outcomes after the use of hip arthroscopy for FAI were included. Outcomes analyzed were RTP rate, RTP level, and criteria used for RTP. Statistical analysis was performed using SPSS software.

RESULTS

Our review found 130 studies, which included 14,069 patients (14,517 hips) and had a mean methodological quality of evidence (MQOE) of 40.4 (range, 5-67). The majority of patients were female (53.7%), the mean patient age was 30.4 years (range, 15-47 years), and the mean follow-up was 29.7 months (range, 6-75 months). A total of 81 studies reported RTP rates, with an overall RTP rate of 85.4% over a mean period of 6.6 months. Additionally, 49 studies reported the rate of RTP at preinjury level as 72.6%. Specific RTP criteria were reported in 97 studies (77.2%), with time being the most commonly reported item, which was reported in 80 studies (69.2%). A total of 45 studies (57.9%) advised RTP at 3 to 6 months after hip arthroscopy.

CONCLUSION

The overall rate of reported RTP was high after hip arthroscopy for FAI. However, more than one-fourth of athletes who returned to sports did not return at their preinjury level. Development of validated rehabilitation criteria for safe return to sports after hip arthroscopy for FAI could potentially improve clinical outcomes while also increasing rates of RTP at preinjury levels.

Extent of Cam Resection Relative to Epiphyseal Line and Its Association With Clinical Outcomes After Arthroscopic Treatment for Femoroacetabular Syndrome

Background:

Inadequate resection of cam lesions can cause inferior outcomes after hip arthroscopy and result in revision surgery for femoroacetabular impingement syndrome (FAIS).

Purpose:

To evaluate the association between postoperative cam lesions measured using the proximal boundaries of resection area (PBRE) relative to the epiphyseal line and 2-year outcomes after hip arthroscopy.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Included were patients with FAIS who had undergone primary hip arthroscopy between 2016 and 2018. The PBRE was calculated by measuring the linear distance from the PBRE to the epiphyseal line, dividing it by the diameter of the femoral head, and multiplying by 100; PBRE measurements were made at the 12-, 1-, and 2-o’clock positions on postoperative hip computed tomography. Within each clockface position, patients were divided into subgroups depending on whether their postoperative PBRE was greater than a half standard deviation above the mean (adequate resection) or less than or equal to a half standard deviation above the mean (inadequate resection). Patient-reported outcomes (PROs; Hip Outcome Score–Activities of Daily Living [HOS-ADL], International Hip Outcome Tool–Short Form [iHOT-12], modified Harris Hip Score [mHHS], and pain visual analog scale [VAS]) and rates of achieving the minimal clinically important difference (MCID) and patient-acceptable symptomatic state (PASS) were compared among the subgroups.

Results:

Included were 80 pairs of hips at 12 o’clock, 81 pairs of hips at 1 o’clock, and 80 pairs of hips at 2 o’clock. All subgroups demonstrated significant improvements in PRO scores at a minimum 2-year follow-up compared with preoperatively. At the 12-o’clock position, the subgroup with adequate resection had significantly superior HOS-ADL ( P = .004), iHOT-12 ( P < .001), and mHHS ( P < .001) scores and were more likely to achieve the MCID for the iHOT-12 score ( P = .035) and the PASS for the HOS-ADL ( P = .003), iHOT-12 ( P = .007), and mHHS ( P < .001) scores compared with the matched subgroup. There were no significant differences in PRO scores or rates of MCID and PASS for the 1- or 2-o’clock groups.

Conclusion:

The epiphyseal line may be a useful and reproducible landmark measurement for cam-type deformity. Patients considered to have inadequate resection at 12 o’clock had lower outcome scores at a minimum 2-year follow-up.

The Presence of Central Acetabular Osteophytes May Negatively Affect the Outcome After Primary Arthroscopic Therapy of Femoroacetabular Impingement Syndrome

PURPOSE

To compare short-term follow-up outcomes after primary arthroscopy in femoroacetabular impingement syndrome (FAIS) patients with untreated central acetabular osteophytes (CAO) to a control group without CAO.

METHODS

A retrospective analysis was performed using data from FAIS patients who had primary arthroscopy between 2017 and 2018. The presence of CAO was confirmed arthroscopically, and there were 2 groups created. The CAO group was 1:1 propensity-score matched to a control group (without CAO) based on age, gender, body mass index (BMI), Tӧnnis grade, symptom duration before surgery, and follow-up time. Patient-reported outcomes (PROs), such as the Hip Outcome Score-Activities of Daily Living (HOS-ADL), International Hip Outcome Tool 12-component form (iHOT-12)，modified Harris Hip Score (mHHS), and visual analog scale (VAS) scores were used to evaluate the level of function included. The minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) were also calculated to determine meaningful outcome improvement. Radiographic measures, performed procedures, complications, and revision surgery were also compared and analyzed for both groups. P values less than .05 were considered statistically significant.

RESULTS

A total of 46 hips with CAO and 46 hips without CAO were propensity matched. At the minimum final follow-up of 2 years, the CAO group had significantly lower HOS-ADL (78.8 vs 85.5; P = .008), iHOT-12 (74.8 vs 79.3; P = .019), and mHHS (78.9 vs 87.2; P = .002) scores, as compared to the CAO group. Furthermore, patients in the CAO group were significantly less likely to achieve the MCID and PASS for the mHHS score (78.3% vs 93.5%; P = .036, 58.7% vs 78.2%; P = .043, respectively). There was no change in the rate of complications (4.3% vs 0%) and revision hip arthroscopy (4.3% vs 2.2%) between the two groups at the final follow-up.

CONCLUSIONS

This study demonstrated that surgically treated FAIS patients with CAO might experience worse short-term, patient-reported outcomes, as compared with propensity-matched patients without CAO.

LEVEL OF EVIDENCE

III, case-control study.

Asymptomatic gluteal tendinosis does not influence outcome in arthroscopic treatment of femoroacetabular impingement syndrome

PURPOSE

To compare outcomes after arthroscopy in FAIS patients with preoperative asymptomatic gluteal tendinosis (GT) to a control group with no gluteal tendinosis.

METHODS

A retrospective analysis was performed using data from FAIS patients who had arthroscopy between 2016 and 2018. Asymptomatic GT was diagnosed using hip MRI without clinical symptoms. Patients with asymptomatic GT were 1:1 propensity-score matched to patients without GT. Patient-reported outcomes (HOS-ADL, iHOT-12, mHHS), VAS scores, radiographic measures, performed procedures, complications, and revision surgery were compared and analyzed for both groups.

RESULTS

A total of 105 asymptomatic GT hips and 105 hips without GT were found using propensity-score matching. When compared to preoperative levels, both groups demonstrated significant improvements in PROs and VAS scores at the final follow-up. Besides, there were no significant differences in preoperative scores, final outcome scores, or score improvements between the groups. Patients in the GT group were significantly less likely to achieve the MCID for the VAS score (72.4% vs 83.8%, p = 0.045). However, there were no other differences in the rate of meeting the PASS and MCID between the study and the control groups.

CONCLUSION

It was demonstrated in this study that FAIS patients with asymptomatic gluteal tendinosis can expect to experience similar good short-term patients-reported outcomes as compared with patients without gluteal tendinosis.

LEVEL OF EVIDENCE

III.

Association Between Preoperative Patient Factors and Clinically Meaningful Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Machine Learning Analysis

BACKGROUND

The International Hip Outcome Tool 12-Item Questionnaire (IHOT-12) has been proposed as a more appropriate outcome assessment for hip arthroscopy populations. The extent to which preoperative patient factors predict achieving clinically meaningful outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) remains poorly understood.

PURPOSE

To determine the predictive relationship of preoperative imaging, patient-reported outcome measures, and patient demographics with achievement of the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and substantial clinical benefit (SCB) for the IHOT-12 at a minimum of 2 years postoperatively.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were analyzed for consecutive patients who underwent hip arthroscopy for FAIS between 2012 and 2018 and completed the IHOT-12 preoperatively and at a minimum of 2 years postoperatively. Fifteen novel machine learning algorithms were developed using 47 potential demographic, clinical, and radiographic predictors. Model performance was evaluated with discrimination, calibration, decision-curve analysis and the brier score.

RESULTS

A total of 859 patients were identified, with 685 (79.7%) achieving the MCID, 535 (62.3%) achieving the PASS, and 498 (58.0%) achieving the SCB. For predicting the MCID, discrimination for the best-performing models ranged from fair to excellent (area under the curve [AUC], 0.69-0.89), although calibration was excellent (calibration intercept and slopes: -0.06 to 0.02 and 0.24 to 0.85, respectively). For predicting the PASS, discrimination for the best-performing models ranged from fair to excellent (AUC, 0.63-0.81), with excellent calibration (calibration intercept and slopes: 0.03-0.18 and 0.52-0.90, respectively). For predicting the SCB, discrimination for the best-performing models ranged from fair to good (AUC, 0.61-0.77), with excellent calibration (calibration intercept and slopes: -0.08 to 0.00 and 0.56 to 1.02, respectively). Thematic predictors for failing to achieve the MCID, PASS, and SCB were presence of back pain, anxiety/depression, chronic symptom duration, preoperative hip injections, and increasing body mass index (BMI). Specifically, thresholds associated with lower likelihood to achieve a clinically meaningful outcome were preoperative Hip Outcome Score-Activities of Daily Living <55, preoperative Hip Outcome Score-Sports Subscale >55.6, preoperative IHOT-12 score ≥48.5, preoperative modified Harris Hip Score ≤51.7, age >41 years, BMI ≥27, and preoperative α angle >76.6°.

CONCLUSION

We developed novel machine learning algorithms that leveraged preoperative demographic, clinical, and imaging-based features to reliably predict clinically meaningful improvement after hip arthroscopy for FAIS. Despite consistent improvements after hip arthroscopy, meaningful improvements are negatively influenced by greater BMI, back pain, chronic symptom duration, preoperative mental health, and use of hip corticosteroid injections.

Determining the Minimal Clinically Important Difference on the Oxford Shoulder Instability Score in Patients Undergoing Arthroscopic Bankart Repair for Shoulder Instability

Background:

The literature on minimal clinically important differences (MCIDs) for patient-reported outcome measures assessing shoulder instability is limited, with none addressing the Oxford Shoulder Instability Score (OSIS). The OSIS was developed to provide a standardized method for assessing shoulder function after surgery for shoulder instability, and previous studies have demonstrated its high reliability, low interrater variability, and ease of administration.

Purpose:

To identify the MCID for the OSIS after arthroscopic Bankart repair for recurrent shoulder instability.

Study Design:

Case series; Level of evidence, 4.

Methods:

A longitudinally maintained institutional registry was queried for patients who underwent arthroscopic Bankart repair from 2010 to 2016 for recurrent shoulder instability secondary to a Bankart lesion without significant glenoid bone loss. The OSIS was completed preoperatively and at 1 year postoperatively. Patients were categorized into “expectations met” and “expectations unmet” groups using a questionnaire evaluating expectation fulfilment. The MCID of the OSIS at 1 year was calculated using 3 anchor-based approaches and a distribution-based approach. The 3 anchor-based approaches comprised (1) simple linear regression analysis, (2) receiver operating characteristic curve analysis, and (3) calculation of mean differences in change for the OSIS between the “expectations met” and “expectations unmet” groups.

Results:

The study cohort comprised 68 men and 11 women aged 29.9 ± 12.7 years (mean ± SD). Duration of follow-up for all patients exceeded 1 year. The MCIDs for the OSIS based on the 4 calculation approaches yielded a narrow range of values, ranging from 7.7 to 8.5 for the anchor-based methods and 8.6 for the distribution-based method.

Conclusion:

Study results indicated that patients with recurrent shoulder instability without significant bone loss who undergo primary arthroscopic Bankart repair and have at least 8.6 points of improvement on their OSIS experience a clinically significant change at 1 year postoperatively.

Research, development, and evaluation of the practical effect of a storage inflow and outflow management system for consumables in the endocrinology department of a hospital

Background

This study was designed for the research and development (R&D) and application of a storage inflow and outflow management system enabling departments to perform efficient, scientific, and information-based consumable management.

Methods

In the endocrinology department of a hospital, expert and R&D teams in consumable management were set up, and an information-based storage inflow and outflow management system for consumables was designed and developed. The system was operated on a personal computer and was divided into three modules: public consumables, bed consumables, and quality control management. The functions of the system included storage inflow and outflow, early warnings, response to user queries, and statistics on consumables. Data were derived from the hospital information system (HIS,ZHIY SOFTWARE HIS VERSION4.0) and a questionnaire survey. Economic indicators, work efficiency of consumable management, nurse burnout, consumable stockroom management, and staff satisfaction were compared under manual management, Excel-based management, and the consumable storage inflow and outflow management system. The results of the questionnaire were analysed using the R software, version 4.1.0.

Results

Dates were obtained from manual management, Excel-based management and the consumable storage inflow and outflow management system. Under these three methods, the daily prices of department consumables per bed were 53.43 ± 10.27 yuan, 38.65 ± 8.56 yuan, and 31.98 ± 7.36 yuan, respectively, indicating that the new management system reduced costs for the department. The time spent daily on consumable management was shortened from 119.5 (106.75, 123.5) min to 56.5 (48.5, 60.75) to 20 (17.25, 24.25) min. Nurses’ emotional fatigue and job indifference scores, respectively, decreased from 22.90 ± 1.65 and 8.75 ± 1.25 under manual management to 19.70 ± 1.72 and 6.90 ± 1.37 under Excel-based management and to 17.20 ± 2.04 and 6.00 ± 1.30 under the novel system; the satisfaction of the warehouse keeper and collection staff, respectively, increased from 76.62% and 80.78% to 91.6% and 90.5% to 98.8% and 98.5% under the three successive systems.

Conclusions

The storage inflow and outflow management system achieved produced good results in the storage and classification of consumables.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01744-y.

Higher satisfaction after total knee arthroplasty using restricted inverse kinematic alignment compared to adjusted mechanical alignment

PURPOSE

Various alignment philosophies for total knee arthroplasty (TKA) have been described, all striving to achieve excellent long-term implant survival and good functional outcomes. In recent years, in search of higher functionality and patient satisfaction, a shift towards more tailored and patient-specific alignment is seen. The purpose of this study was to describe a restricted 'inverse kinematic alignment' (iKA) technique, and to compare clinical outcomes of patients that underwent robotic-assisted TKA performed by restricted iKA vs. adjusted mechanical alignment (aMA).

METHODS

The authors reviewed the records of a consecutive series of patients that received robotic-assisted TKA with restricted iKA (n = 40) and with aMA (n = 40). Oxford Knee Score (OKS) and satisfaction on a visual analogue scale (VAS) were collected at a follow-up of 12 months. Clinical outcomes were assessed according to patient acceptable symptom state (PASS) thresholds, and uni- and multivariable linear regression analyses were performed to determine associations of OKS and satisfaction with six variables (age, sex, body mass index (BMI), preoperative hip-knee-ankle (HKA) angle, preoperative OKS, alignment technique).

RESULTS

The restricted iKA and aMA techniques yielded comparable outcome scores (p = 0.069), with OKS, respectively, 44.6 ± 3.5 and 42.2 ± 6.3. VAS Satisfaction was better (p = 0.012) with restricted iKA (9.2 ± 0.8) compared to aMA (8.5 ± 1.3). The number of patients that achieved OKS and satisfaction PASS thresholds was significantly higher (p = 0.049 and p = 0.003, respectively) using restricted iKA (98% and 80%) compared to aMA (85% and 48%). Knees with preoperative varus deformity, achieved significantly (p = 0.025) better OKS using restricted iKA (45.4 ± 2.0) compared to aMA (41.4 ± 6.8). Multivariable analyses confirmed better OKS (β = 3.1; p = 0.007) and satisfaction (β = 0.73; p = 0.005) with restricted iKA.

CONCLUSIONS

The results of this study suggest that restricted iKA and aMA grant comparable clinical outcomes at 12-month follow-up, though a greater proportion of knees operated by restricted iKA achieved the PASS thresholds for OKS and satisfaction. Notably. in knees with preoperative varus deformity, restricted iKA yielded significantly better OKS and satisfaction than aMA.

LEVEL OF EVIDENCE

Level III, comparative study.

Collection of the International Hip Outcome Tool-12 Using a Smartphone Application Format Is Faster and Preferred When Compared With the Paper Version: A Pilot Study of rHip

Purpose

To evaluate the agreeability between the mobile application-based International Hip Outcome Tool-12 (iHOT-12) survey with the paper version, as well as compare the time it takes patients each of the versions, and patient preferences between the two.

Methods

Patients seen with symptomatic femoroacetabular impingement syndrome were prospectively enrolled in February 2019 and completed both the paper and application-based iHOT-12, in randomized order. Outcomes scores and time to completion were recorded for each version, and patients were also asked which they preferred. Intraclass correlation coefficient was calculated to assess for absolute agreement between the 2 versions. Bland–Altman plots were constructed to evaluate the agreeability between paper and application-based iHOT-12 scores. Bland–Altman plots were evaluated to identify systematic bias and data stratification was performed to identify sequence bias between the application and paper-based collection modalities.

Results

Twenty-nine patients (aged15-56 years) completed both the paper and application-based versions of the iHOT-12. Between the application-based and paper versions, the intraclass correlation coefficient was 0.98, and Bland–Altman analysis showed agreement without bias between versions. There was no sequence bias. Accounting for completion order, the application-based iHOT-12 was faster for patients when compared to the paper version (61.4 ± 20.3 vs 71.9 ± 23.6 seconds, P = .02). Twenty-two patients reported a version preference where 19 of 22 (86%) chose application-based (P < .001).

Conclusions

The application-based iHOT-12 demonstrated absolute agreement with the paper iHOT-12, and is faster for patients to complete. Patients preferred using the application-based iHOT-12 over the paper-based version. Application-based PROs allow for collection of patient data at more frequent time points, which may be helpful in tracking the recovery progress of patients and predicting outcomes.

Clinical Relevance

As electronic-based outcome surveys become more common, it is important to know how the results may differ from traditional paper-based surveys.

Determining Clinically Meaningful Thresholds for the Nonarthritic Hip Score in Patients Undergoing Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

The purpose of this study was to improve the interpretability of the Nonarthritic Hip Score (NAHS) by determining the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) after hip arthroscopy for femoroacetabular impingement. The secondary aim was to identify variables associated with achievement of the thresholds.

METHODS

Patients who underwent hip arthroscopy for femoroacetabular impingement and completed postoperative questionnaires between August 2019 and March 2020 were included. Patients were excluded if they underwent previous ipsilateral hip surgery, underwent gluteus medius repair, or had a previous hip condition. The MCID, PASS, and SCB thresholds were calculated for the NAHS at minimum 1-, 2-, and 5-year follow-up. Distribution- and anchor-based methods with receiver operating characteristic analysis were used to determine the thresholds. Multivariate logistic regression was performed to determine predictors of achieving the MCID and PASS.

RESULTS

The study included 343 hips with an average follow-up period of 48 months. On the basis of the distribution-based approach, the MCID was 8.7 using a method in which the standard deviation of the baseline score was divided by 2. By use of a method in which the standard deviation of the change score was divided by 2, MCID scores of 9.1, 8.3, and 12.6 resulted at a minimum of 1, 2, and 5 years, respectively. The PASS thresholds for these time points were 81.9, 85.6, and 81.9. The absolute SCB thresholds were 91.9, 94.4, and 93.1 and the change score thresholds were 30.6, 24.4, and 29.3 for a minimum of 1, 2, and 5 years, respectively. The preoperative NAHS was positively associated with achievement of the PASS and inversely related to achievement of the MCID.

CONCLUSIONS

This study provides important clinical thresholds for the NAHS. These thresholds were determined for minimum 1-, 2-, and 5-year time points. The MCID was determined as 8.7, the PASS ranged between 81.9 and 85.6, and the absolute SCB value ranged from 91.9 to 94.4. The preoperative NAHS was found to be positively associated with achievement of the PASS and inversely related to achievement of the MCID.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Gender and Age-Specific Differences Observed in Rates of Achieving Meaningful Clinical Outcomes 5-Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To compare the impact of age and gender on achieving meaningful outcomes among minimum patients 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Consecutive patients undergoing hip arthroscopy for FAIS by a single fellowship-trained surgeon between January 2012 and October 2014 were analyzed. Study inclusion criteria included any patient undergoing primary hip arthroscopy for FAIS, with 5 years follow-up. Preoperative and 5-year postoperative functional scores were collected, including the Hip Outcome Score Activities of Daily Living Subscale (HOS-ADL), HOS-Sport Subscale (HOS-SS), modified Harris hip score (mHHS), and Visual Analog Scale for satisfaction. Patients were matched 1:1 by gender and age to compare outcomes between these 2 demographics. Minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) were calculated for each functional measure and compared by gender and age.

RESULTS

Of the 340 patients (70.5%) with 5 years' follow up, 150 were matched by gender and age into one of the following groups: female patients <30 years, female patients 30 to 45 years, female patients >45 years, male patients <30 years, male patients 30 to 45 years, and male patients >45 years of age. At minimum 5-year follow-up, all 6 groups demonstrated statistically significant improvement in the functional outcome score averages and pain (P < .001 for all). Both within gender and within age category analysis of postoperative functional scores did not demonstrate any statistical differences (P > .05). Analysis of achieving MCID and PASS demonstrated that females had higher rates of reaching the HOS-SS and mHHS threshold for achieving MCID as compared to their male counterparts (P < .05). Furthermore, patients <30 years old had higher rates of reaching the HOS-ADL and mHHS for achieving PASS when compared to patients >45 years old (P < .05).

CONCLUSION

The majority of patients achieve clinically significant outcome improvement at 5-year follow-up after arthroscopic FAIS surgery. Females reach the mHHS threshold for achieving MCID at significantly higher rates than males. Patients <30 years of age achieved PASS on the HOS-ADL and mHHS threshold scores at higher rates than those >45 years old.

LEVEL OF EVIDENCE

Level III, case-control study.

The Fragility Index of Hip Arthroscopy Randomized Controlled Trials: A Systematic Survey

PURPOSE

To characterize the fragility index (FI) of statistically significant results from randomized controlled trials (RCTs) in hip arthroscopy.

METHODS

The PubMed-MEDLINE, Embase, and Cochrane databases were queried for hip arthroscopy RCTs published between January 2010 and July 2020. RCTs were included if they contained only 2 treatment arms, randomized patients to a 1:1 allocation to each arm, and reported at least 1 statistically significant dichotomous outcome. The fragility quotient was calculated for each RCT by dividing the FI by the sample size. Smaller FIs indicated more fragile results. Risk of bias was assessed using the Cochrane risk-of-bias tool for randomized trials.

RESULTS

We identified 8 hip arthroscopy RCTs that met all inclusion and exclusion criteria. Most of the studies were assessed to have an overall low risk of bias. In the 2 studies with a moderate risk of bias and 1 study with a high risk of bias, concerns were raised about high rates of crossover and loss to follow-up. The median FI was 4, with FIs ranging from 0 to 14, but half of the studies had an FI of 2 or less. In 4 of the 8 studies, the number of patients lost to follow-up was greater than the FI.

CONCLUSIONS

A systematic survey of hip arthroscopy RCTs resulted in a low FI, indicating that the findings tended to be fragile. A low FI was consistent with findings reported in other orthopaedic and medical literature. Given these results, there is a possibility for findings to be altered by factors such as loss to follow-up, measurement subjectivity, crossover, and biased study design. Results on the fragility of hip arthroscopy RCTs were similar to those reported in general or orthopaedic-specific literature.

LEVEL OF EVIDENCE

Level II, systematic review of Level I and II studies.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Provides Clinically Significant Outcome Benefit at Minimum 5-Year Follow-Up

PURPOSE

To report the rates of achieving clinically significant outcomes as defined by the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), or substantial clinical benefit (SCB) in adolescent patients and the rates of clinical failure 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive adolescent patients (defined by the American Academy of Pediatrics as age 11 to 21 years) who underwent primary hip arthroscopy with routine capsular closure for the treatment of FAIS between January 2012 and January 2015 by a single, fellowship-trained surgeon was collected. Baseline data, clinical outcomes including Hip Outcome Score (HOS)-Activities of Daily Living, HOS-Sports Subscale, modified Harris hip score, international Hip Outcome Tool, and clinical failure rates were recorded at 5 years after operative. Clinical failure was defined by revision hip arthroscopy or conversion to total hip arthroplasty. Clinically significant outcomes was defined as achieving MCID, PASS, or SCB on at least 1 hip-specific outcome measure.

RESULTS

Of the 139 eligible patients, a total of 85 (60.4%) patients (85 hips) were included in the final analysis, with an age and body mass index average of 17.6 ± 2.5 years (range 13-21) and 22.3 ± 3.1 kg/m², respectively. The majority of the patients were female (80.6%) and participated in sports (76.2%). There was statistically significant difference between preoperative and postoperative score averages across every reported outcome (P < .001). At 5 years, 88.4%, 67.6%, and 64.9% reached at least 1 threshold for achieving MCID, PASS, and SCB, respectively, whereas 89.2% achieved at least one of the meaningful outcome thresholds. Last, 2 patients (2.4%) failed clinically, with both undergoing revision (2.4%) because of continued pain. There were no conversions to total hip arthroplasty.

CONCLUSION

This study demonstrated that a large majority (89.2%) of adolescent patients undergoing primary arthroscopic treatment for symptomatic FAIS achieved meaningful clinically significant outcomes. Furthermore, only 2.4% of patients failed clinically, requiring revision hip arthroscopy because of continued pain.

LEVEL OF EVIDENCE

IV, Retrospective Case Series.

Machine Learning Algorithms Predict Clinically Significant Improvements in Satisfaction After Hip Arthroscopy

PURPOSE

To develop machine learning algorithms to predict failure to achieve clinically significant satisfaction after hip arthroscopy.

METHODS

We queried a clinical repository for consecutive primary hip arthroscopy patients treated between January 2012 and January 2017. Five supervised machine learning algorithms were developed in a training set of patients and internally validated in an independent testing set of patients by discrimination, Brier score, calibration, and decision-curve analysis. The minimal clinically important difference (MCID) for the visual analog scale (VAS) score for satisfaction was derived by an anchor-based method and used as the primary outcome.

RESULTS

A total of 935 patients were included, of whom 148 (15.8%) did not achieve the MCID for the VAS satisfaction score at a minimum of 2 years postoperatively. The best-performing algorithm was the neural network model (C statistic, 0.94; calibration intercept, -0.43; calibration slope, 0.94; and Brier score, 0.050). The 5 most important features to predict failure to achieve the MCID for the VAS satisfaction score were history of anxiety or depression, lateral center-edge angle, preoperative symptom duration exceeding 2 years, presence of 1 or more drug allergies, and Workers' Compensation.

CONCLUSIONS

Supervised machine learning algorithms conferred excellent discrimination and performance for predicting clinically significant satisfaction after hip arthroscopy, although this analysis was performed in a single population of patients. External validation is required to confirm the performance of these algorithms.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Large Heterogeneity Among Minimal Clinically Important Differences for Hip Arthroscopy Outcomes: A Systematic Review of Reporting Trends and Quantification Methods

PURPOSE

To perform a systematic review of reporting trends and quantification methods for the minimal clinically important difference (MCID) within the hip arthroscopy literature.

METHODS

Cochrane, PubMed, and OVID/MEDLINE databases were queried for hip arthroscopy articles that reported the MCID. Studies were classified as (1) calculating new MCID values for their specific study-population or (2) referencing previously established MCID values. Data pertaining to patient demographics, study characteristics, outcome measures, method of MCID quantification, MCID value, anchor questions, measurement error, and study from which referenced MCID values were obtained were extracted.

RESULTS

A total of 59 articles with 18,830 patients (19,867 hips) was included. A total of 19 unique outcome measures was reported. A total of 33 (n = 55.9%) studies (follow-up range 6-60 months) used previously established MCID values to assess their study population (MCID values established at a follow-up range 6-31 months). The remaining 26 studies (44.1%) performed new MCID calculations. The MCID values were inconsistent and varied widely (Hip Outcome Score-Activities of Daily Living: 5.0-15.4; Hip Outcome Score-Sports Subscale: 6-25; modified Harris hip score: 2.4-20.9). Among the 33 studies that used previously established MCID values, 10 different studies were cited as the reference. Among the remaining 26 studies that calculated a new MCID value, the most common method was 0.5 standard deviation method (n = 21, 80.8%). Only 3 of 26 (11.5%) studies reported a measurement of error in conjunction with their MCID values.

CONCLUSIONS

Inconsistencies in MCID reporting and quantification methods led to a wide range of MCID values for commonly administered outcome measures within the hip arthroscopy literature-even for the same outcome measures. The majority of studies referenced previously established MCID values with variable ranges of follow-up and applied those values to assess their specific study population at varying follow-ups.

LEVEL OF EVIDENCE

IV, systematic review.

Hip Arthroscopy for Femoroacetabular Impingement: 1-Year Outcomes Predict 5-Year Outcomes

BACKGROUND

Limited evidence exists comparing short- and long-term patient-reported outcomes (PROs) and overall survival rates after hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

HYPOTHESIS

Patients with high improvement (HI) versus low improvement (LI) at 1 year postoperatively would achieve higher PROs and better index procedure survival rates at 5-year follow-up.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopy for FAIS between September 2012 and March 2014 with minimum 5-year outcome data were identified. Using the median 1-year change in modified Harris Hip Score (mHHS) as a threshold, HI and LI subcohorts were determined. Analysis of variance was used to compare PROs. Failure rates were determined using Kaplan-Meier and Cox proportional hazards model analyses. Regression analysis was used to identify factors associated with increasing 5-year change in mHHS and Nonarthritic Hip Score (NAHS).

RESULTS

Out of 108 eligible consecutive patients, 89 (82.4%) were included (mean [SD]: age, 43.3 [14.6] years; body mass index, 25.4 [4.5]). As compared with the LI group (n = 45), the HI group (n = 44) had a longer 5-year index surgery survival rate (mean ± SEM: 83.7 ± 3.3 months vs 68.5 ± 4.6 months; P = .012) and 5-year estimated survival rate (89% vs 71%). The HI group had a decreased risk of failure versus the LI group (hazard ratio, 0.15; P = .002). The HI group also had greater PROs than did the LI group at 1 year (mHHS: 94.8 ± 1.2 vs 72.6 ± 2.7, P < .001; NAHS: 94.0 ± 1.3 vs 75.6 ± 2.2, P < .001) and 5 years (mHHS: 86.9 ± 2.0 vs 77.6 ± 3.4, P = .017; NAHS: 92.6 ± 1.8 vs 82.7 ± 4.1, P = .020). As compared with the LI group, the HI group achieved higher rates of the Patient Acceptable Symptomatic State (PASS) and minimal clinically important difference (MCID) at 1 year (PASS: 95% vs 42%, P < .001; MCID: 100% vs 89%, P = .056) and 5 years (PASS: 77% vs 45%, P = .002; MCID: 86% vs 64%, P = .014). Linear regression demonstrated that being in the HI group (ΔmHHS, P = .041; ΔNAHS, P = .017) and decreasing body mass index (ΔmHHS, P = .055; ΔNAHS, P = .023) were associated with higher 5-year ΔPROs.

CONCLUSION

Patients with FAIS and significant improvement in the first year after hip arthroscopy had superior 5-year outcomes versus patients with persistent symptom severity. Survival rates and PROs were significantly better in patients who achieved high early outcomes at the 1-year mark.

Clinical and Radiographic Outcome of Gap Balancing Versus Measured Resection Techniques in Total Knee Arthroplasty

Background

There is no consensus regarding superiority between gap balancing (GB) and measured resection (MR) techniques to implant total knee arthroplasties. In a multicenter setup, we compared both techniques using the same prosthesis.

Methods

We included 262 balanSys posterior-stabilized total knee arthroplasties from 4 centers: 3 using the MR (n = 162) and one using the GB technique (n = 100), without navigation.

Results

There was no significant difference in the Knee Society Score or visual analog scale pain at 2- and 7-year follow-up. The visual analog scale for satisfaction was significantly better in the MR group at 2 but not at 7 years. We found a significantly higher average valgus in the GB group, but the overall alignment was within 2° of neutral on the full-leg radiographs. There were no significant differences concerning radiolucency and survival.

Conclusions

We found no significant differences in the functional outcome, pain, alignment, or survival, but a tendency toward better function using MR and better survival with GB.

Is the minimal clinically important difference (MCID) in acute pain a good measure of analgesic efficacy in regional anesthesia?

In the field of acute pain medicine research, we believe there is an unmet need to incorporate patient related outcome measures that move beyond reporting pain scores and opioid consumption. The term “minimal clinically important difference” (MCID) defines the clinical benefit of an intervention as perceived by the patient, as opposed to a mathematically determined statistically significant difference that may not necessarily be clinically significant. The present article reviews the concept of MCID in acute postoperative pain research, addresses potential pitfalls in MCID determination and questions the clinical validity of extrapolating MCID determined from chronic pain and non-surgical pain studies to the acute postoperative pain setting. We further suggest the concepts of minimal clinically important improvement, substantial clinical benefit and patient acceptable symptom state should also represent aspirational outcomes for future research in acute postoperative pain management.

Patients With Borderline Hip Dysplasia Achieve Clinically Significant Improvement After Arthroscopic Femoroacetabular Impingement Surgery: A Case-Control Study With a Minimum 5-Year Follow-up

BACKGROUND

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) in patients with borderline hip dysplasia (BHD) is becoming a more common practice. However, the literature on achieving meaningful outcomes at midterm follow-up, as well as predictors of these outcomes, is limited.

PURPOSE

To (1) compare the rates of achieving meaningful clinical outcomes between patients with and without BHD and (2) identify the predictors for achieving clinical success among patients with BHD 5 years after undergoing hip arthroscopic surgery for FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data from consecutive patients who underwent primary hip arthroscopic surgery with routine capsular closure for the treatment of FAIS between January 2012 and August 2014 were collected and retrospectively analyzed. Patients with BHD (lateral center-edge angle [LCEA] 20°-25°) were matched 1:2 by age (±1 year) and body mass index (BMI; ±5 kg/m²) to control patients with normal acetabular coverage (LCEA 25°-40°). Data collected included baseline and 5-year postoperative patient-reported outcomes. The minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) were calculated for each patient-reported outcome measure and compared between the 2 groups. A binary logistic regression analysis was used to identify significant predictors of achieving the MCID and PASS in the BHD group.

RESULTS

The MCID in the BHD group was defined as 9.6, 14.1, and 9.5 for the Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Subscale, and modified Harris Hip Score, respectively. Threshold scores for achieving the PASS in both groups were 90.9, 76.6, and 81.9, respectively. A total of 88 patients were identified with having BHD and were matched to 176 controls. No statistical differences were identified for age, BMI, or sex. Both the BHD and the non-BHD groups had statistically significant increases in patient-reported outcome scores over the 5-year period, but the difference in both groups was not statistically significant (P > .05 for all). There was no statistical difference in the frequency of patients in the BHD and non-BHD groups achieving the MCID (86.6% vs 85.2%, respectively; P = .804) or PASS (76.0% vs 73.7%, respectively; P = .675) on at least 1 outcome measure. The logistic regression model demonstrated that being physically active (odds ratio [OR], 27.59; P = .005) and being female (OR, 14.64; P = .025) were independent predictors of achieving the MCID, while running (OR, 11.1; P = .002), being female (OR, 7.6; P = .011), and a larger preoperative LCEA (OR, 2.3; P = .001) were independent preoperative predictors of achieving the PASS.

CONCLUSION

The rates of achieving clinical success 5 years after undergoing arthroscopic treatment with capsular closure for FAIS were not significantly different between patients with BHD and those with normal acetabular coverage. Being physically active, running for exercise, female sex, and a larger LCEA were preoperative predictors of achieving clinical success at 5 years in patients with BHD.

Editorial Commentary: Quantifying Patient Satisfaction After Hip Arthroscopy: I Cannot Deactivate Until You Are Satisfied With Your Care

The evolution of hip-preservation research is now streamlining toward evaluating our results as they relate to minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit and less to P value-only significance. The keystone to successful hip-preservation procedures lies in proper patient selection, expert surgical execution, following results, and measuring satisfaction over time. Having a truly objective measure for establishing patient satisfaction is paramount to guiding surgical success.