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

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.

Outcomes of Arthroscopic Decompression of the Anterior Inferior Iliac Spine: A Systematic Review and Meta-analysis

BACKGROUND

Anterior inferior iliac spine (AIIS) impingement has been increasingly recognized as a source of extra-articular impingement and hip pain. However, no aggregate data analysis of patient outcomes after AIIS decompression has been performed.

PURPOSE

To evaluate outcomes after arthroscopic AIIS decompression.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were queried for all English-language studies reporting outcomes of arthroscopic AIIS decompression performed in isolation or in conjunction with hip impingement correction surgery. After screening, 10 articles were included. The indications for AIIS decompression were recorded, and weighted mean improvements in patient-reported outcome (PRO) scores, complication rates, and revision rates were calculated.

RESULTS

A total of 547 patients (311 women; 57%) were identified, with a total of 620 operative hips. The mean age was 28.42 ± 5.6 years, and the mean follow-up was 25.22 ± 11.1 months. A total of 529 hips (85%) underwent AIIS decompression, 530 hips (85%) underwent femoral osteochondroplasty, and 458 hips (74%) underwent labral repair. Of the patients, 13% underwent bilateral AIIS decompression. The mean modified Harris Hip Score improved from 61.3 ± 6.9 to 88.7 ± 4.7 postoperatively (change, 27.4 ± 5.7 points; P < .001), the Hip Outcome Score-Activities of Daily Living improved from 67.2 ± 10.6 to 91.1 ± 3.2 postoperatively (change, 24.0 ± 8.0 points; P = .001), and the Hip Outcome Score-Sports Specific Subscale improved from 36.8 ± 19.2 to 82.8 ± 3.8 postoperatively (change, 46.0 ± 18.2 points; P = .002). The pooled risk of postoperative complications was 1.1% (95% CI, 0.1%-2.1%), and the pooled risk of needing revision surgery was 1.0% (95% CI, 0.1%-2.0%). No complication was directly attributed to the AIIS decompression portion of the procedure.

CONCLUSION

PROs improved significantly after hip arthroscopy with AIIS decompression, with a low risk of postoperative complications and subsequent revision surgeries. Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the AIIS, could lead to poorer outcomes and future revision surgery.

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.

The minimal clinically important difference for the nonarthritic hip score at 2-years following hip arthroscopy

PURPOSE

The purpose of this study was to determine and establish the MCID for the NAHS at 2 years in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients that underwent primary hip arthroscopy for FAIS between 2010 and 2016 were analyzed for eligibility. Data were collected from a single surgeon's hip arthroscopy database. MCID was calculated for the NAHS utilizing a distribution-based method.

RESULTS

The study included 298 patients (184 females) with an average age of 40.4 ± 13.0 years and average body mass index (BMI) of 25.7 ± 4.2 kg/m². At baseline, the cohort's average NAHS score was 48.7 ± 13.6 and demonstrated an improvement of 36.5 ± 17.0 for NAHS at follow-up. This resulted in MCID values of + 8.5 for NAHS.

CONCLUSION

This is the first study to report the MCID (+ 8.5) for NAHS following primary hip arthroscopy, and as such, is a valuable contribution to future hip arthroscopy research.

LEVEL OF EVIDENCE

IV.

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.

Return to Sports and Minimum 2-Year Outcomes of Bilateral Hip Arthroscopy in High-Level Athletes With a Propensity-Matched Benchmarking Against a Unilateral Control Group

BACKGROUND

Return to sports (RTS) and patient-reported outcomes (PROs) for high-level athletes after bilateral hip arthroscopy have not been well established.

PURPOSE

(1) To report minimum 2-year PROs and RTS rates in high-level athletes who underwent staged bilateral primary hip arthroscopies and (2) to compare clinical results against a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high-level athletes (professional, college, or high school) who underwent staged bilateral hip arthroscopy for femoroacetabular impingement syndrome between September 2009 and October 2018. Inclusion criteria were preoperative and minimum 2-year follow-up for modified Harris Hip Score, Non-arthritic Hip Score, Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery/conditions. Rates of achieving the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. These athletes were then propensity matched in a 1:3 ratio to high-level athletes who underwent unilateral arthroscopy for comparison. Outcomes were compared among the first hip of the study group, the second hip of the study group, and the control group.

RESULTS

A total of 74 high-level athletes who underwent bilateral hip arthroscopy met the inclusion criteria, and follow-up was available for 68 (91.9%) at 58.9 ± 24.5 months (mean ± SD). Athletes undergoing bilateral hip arthroscopy returned to sports at a high rate (81.7%), demonstrated significant improvements in all recorded PROs, and achieved the MCID and PASS for the HOS-SSS at rates of 80.9% and 64.7%, respectively. PROs, RTS rate, and rates of achieving the MCID and PASS for the HOS-SSS were similar when the bilateral study group was compared with the unilateral control group (P > .05).

CONCLUSION

High-level athletes who undergo staged bilateral primary hip arthroscopy for femoroacetabular impingement syndrome may expect favorable PROs and RTS rates at minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of high-level athletes who underwent unilateral primary hip arthroscopy.

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.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Editorial Commentary: Bilateral Femoroacetabular Impingement Syndrome: What We Know Now and Where Do We Go From Here?

Patients with bilateral femoroacetabular impingement syndrome treated with either staged or simultaneous hip arthroscopy have similar postoperative outcomes compared with patients undergoing unilateral procedures. A longer duration between surgeries is associated with inferior outcomes; however, the reasons underlying this trend are unclear. Identifying prognostic variables that are associated with contralateral symptom onset and disease progression are important goals for future investigation.