Competitive Athletes Who Underwent Hip Arthroscopy With Capsular Repair Showed Greater Improvement in Patient-Reported Outcome Scores Compared With Those Who Did Not Undergo Repair

High-Level Competitive Athletes Who Undergo Hip Arthroscopy Demonstrate Durable 5-Year Outcomes and Lower Subjective Pain: A Propensity-Matched Analysis

BACKGROUND

Hip arthroscopy (HA) has been proven to be an effective treatment for femoroacetabular impingement syndrome (FAIS) in both competitive athletes (CA) and non-CA at short-term follow-up. However, there is a paucity of literature investigating midterm outcomes comparing athletes with Controls.

HYPOTHESIS

Athletes would have significant improvements at 5 years, with favorable outcomes compared with their control counterparts, and high return-to-sport (RTS) rate.

STUDY DESIGN

Propensity-matched retrospective comparative cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

CAs who underwent primary HA for FAIS from January 1, 2012 to April 30, 2017 were identified and propensity matched on a 1:4 basis to Controls by age, sex, and body mass index (BMI). Patient-reported outcomes (PROs) were collected preoperatively and at 5 years. Minimal clinically important differences (MCID) and patient acceptable symptom states (PASS) rates were calculated using previously published thresholds. Rate and duration of RTS were collected retrospectively.

RESULTS

A total of 57 high-level CA (33 female, 24 male; age, 21.7 ± 4.2 years; BMI, 23.1 ± 2.8 kg/m2) were propensity matched to 228 Controls (132 female, 96 male; P > 0.99; age, 23.3 ± 5.8 years; P = 0.02; BMI, 23.8 ± 4.3 kg/m2, P = 0.24). Significant differences were observed in preoperative Hip Outcome Score Sports Specific and Activities of Daily Living (HOS-ADL) subscales (CA, 74.9 ± 13.7 vs Controls, 66.4 ± 18.4; P = 0.01) and modified Harris Hip Score (mHHS) (CA, 64.7 ± 12.9 vs Controls, 59.7 ± 14.3; P = 0.04). Both groups demonstrated significant postoperative improvements in all outcome scores measured (P ≤ 0.01). At 5 years postoperatively, there were significant differences between groups in Visual Analog Scale (VAS) Pain (CA, 17.3 ± 17.6 vs Controls, 24.7 ± 25.9; P = 0.02). There were no significant differences in achieving MCID or PASS. Athletes RTS at a median of 25.2 weeks (Q1 22.4-Q3 30.7) with an overall RTS rate of 90%. Similar rates of revision were seen between CA patients (n = 3; 5.3%) and Control patients (n = 9; 3.9%) (P = 0.66).

CONCLUSION

CAs demonstrated significant and durable improvements in PROs as well as high MCID and PASS achievement rates after primary HA, which were comparable with those of Controls. Clinicians should be aware that CA patients demonstrate higher preoperative mHHS and HOS-ADL scores than Controls and achieve lower average self-reported pain at 5 years postoperatively. In addition, CA patients demonstrate high rates of RTS at a median of 25 weeks postoperatively.

CLINICAL RELEVANCE

This study provides insight into CA versus Control PROs and rates of achieving MCID and PASS at a midterm follow-up of 5 years. Furthermore, this study offers perception into RTS rate, both in general as well as specified to individualized sports.

Long-term Survivorship and Outcomes of Patients Without Dysplasia Undergoing Capsular Repair During Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

There is a paucity of literature evaluating long-term outcomes and survivorship of patients undergoing primary hip arthroscopy with capsular repair for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To report 10-year survivorship and patient-reported outcomes (PROs) after primary hip arthroscopy with capsular repair for FAIS and evaluate the effect of capsular repair in patients at the highest risk for conversion to arthroplasty.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing primary hip arthroscopy with capsular repair between October 2008 and February 2011. Patients with a minimum 10-year follow-up on the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale for pain (VAS) scores were selected. The preoperative and minimum 10-year follow-up Hip Outcome Score-Sports Specific Subscale (HOS-SSS) scores were also reported, if available. Patients with ipsilateral hip surgery, worker's compensation, Tönnis osteoarthritis grade >1, and hip dysplasia (lateral center-edge angle <25°) were excluded. Survivorship, PROS, and clinical benefit-minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS)-were reported. An additional propensity-matched subanalysis was performed on patients at the highest risk for conversion to arthroplasty, comparing patients undergoing capsular repair to patients with unrepaired capsules.

RESULTS

A total of 145 (n = 130 patients) out of 180 eligible hips (n = 165 patients) had a minimum 10-year follow-up (80.6%). Also, 126 hips (86.9%) belonged to women, and 19 hips (13.1%) belonged to men. The mean patient age was 30.3 ± 12.9 years. The survivorship rate was 91% at the 10-year follow-up. The cohort experienced significant improvements (P < .001) in the mHHS, NAHS, HOS-SSS, and VAS for pain scores. Moreover, the cohort achieved high rates of the PASS for the mHHS (89.8%), high rates of the MCID for the mHHS (82.4%), and high rates of the MCID for VAS for pain (80.6%) scores. In the propensity-matched subanalysis performed on patients with the highest risk for arthroplasty, 29 hips with capsular repair were matched to 81 hips with unrepaired capsules. While both groups experienced significant improvements in all PROs (P < .05), the group without capsule repair trended toward a higher conversion to arthroplasty rate when compared with the repair group. In addition, an odds ratio was calculated for the likelihood of converting to arthroplasty after having an unrepaired capsule compared with capsular repair (2.54 [95% CI, 0.873-7.37]; P = .087).

CONCLUSION

Patients undergoing primary hip arthroscopy with capsular repair experienced a high survivorship rate of 91% at a minimum 10-year follow-up. Patients who did not convert to arthroplasty saw favorable improvements in PROs and achieved high clinical benefit rates. In addition, among those patients at the highest risk for conversion to arthroplasty, a trend toward greater survivorship was observed with capsular repair.

Capsular Repair Versus No Repair After Hip Arthroscopy in Patients Without Dysplasia or Generalized Ligamentous Laxity: A Systematic Review and Meta-analysis

Background

Many recent studies have shown that patients who undergo capsular repair after hip arthroscopy achieve superior clinical outcomes compared with those who do not. However, patients with dysplasia or generalized ligamentous laxity (GLL) were not excluded from most of these studies, which may have affected the outcomes.

Purpose

To determine whether capsular repair influences the outcomes of hip arthroscopy for patients without dysplasia or GLL.

Study Design

Systematic review; Level of evidence, 1.

Methods

Under the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, randomized controlled trials comparing the outcomes of capsulotomy with versus without repair were included, but studies that included patients with dysplasia or GLL were excluded. The study outcomes were patient-reported outcome measures (PROMs) at 6 months and 2 years postoperatively-including the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS)- and were compared between the repair and no-repair groups. A narrative analysis and meta-analysis were performed to integrate and compare the results of the 2 groups. In the meta-analysis of the outcome measures, studies with significant differences in the preoperative scores between the repair and no-repair groups were excluded because previous studies have shown that these can affect the outcomes.

Results

A total of 761 studies were initially identified, of which 3 were included. Of the 322 included patients, 136 underwent capsular repair, and 186 underwent capsulotomy with no repair. The meta-analysis showed that capsular repair was associated with significantly higher postoperative PROMs: the mHHS at 2 years (P = .03), the HOS-ADL at 6 months (P = .02) and 2 years (P < .0001), and the HOS-SSS at 6 months (P = .02) and 2 years (P = .001).

Conclusion

Capsular repair after hip arthroscopy was associated with superior clinical outcomes when compared with no capsular repair in patients without dysplasia or GLL.

Long-term Outcomes of Primary Hip Arthroscopy: Multicenter Analysis at Minimum 10-Year Follow-up With Attention to Labral and Capsular Management

BACKGROUND

Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited.

PURPOSE

To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes-including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations.

RESULTS

A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation-including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P≤ .039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P = .006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P = .085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P = .033).

CONCLUSION

At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation-including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair.

Dancers Show Significant Improvement in Outcomes and Favorable Return-to-Dance Rates After Primary Hip Arthroscopy With Femoral Head Cartilage Status Being a Predictor of Secondary Surgical Procedures at Mid-Term Follow-Up

PURPOSE

To report minimum 5-year follow-up patient-reported outcome measurement (PROM) scores and return-to-dance rates in dancers who underwent primary hip arthroscopy and to identify predictors of secondary surgical procedures.

METHODS

Prospectively collected data from patients who underwent hip arthroscopy between May 2010 and June 2016 were retrospectively reviewed. Patients were included if they participated in dance at any level 1 year prior to surgery and had preoperative and minimum 5-year follow-up scores consisting of the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale pain score. The exclusion criteria were previous hip conditions, previous ipsilateral hip surgery, Tönnis grade greater than 1, or lateral center-edge angle less than 18°. The minimal clinically important difference (MCID) was reported. Dancers who discontinued dance for reasons other than pain in the operative hip were excluded from the return-to-dance analysis. A logistic regression model was used to identify predictors of secondary surgical procedures.

RESULTS

Fifty-one hips (48 female dancers) were included. The average age and average follow-up period were 29.8 ± 17.2 years and 79.1 ± 23.2 months, respectively. Improvement in all PROM scores (P < .001) was reported. Achievement rates of the MCID for the modified Harris Hip Score, Nonarthritic Hip Score, and visual analog scale pain score were 83.3%, 85.7%, and 85.7%, respectively. Revision hip arthroscopy was performed in 5 dancers (9.8%). Conversion to total hip arthroplasty was performed in 4 dancers (7.8%). The return-to-dance rate was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was identified as a predictor of secondary surgical procedures (P = .045; odds ratio, 6.752 [95% confidence interval, 1.043-43.688]).

CONCLUSIONS

After primary hip arthroscopy, dancers experienced significant improvement in all PROM scores collected and achieved the MCID at a high rate at minimum 5-year follow-up. The return-to-dance rate in dancers who did not discontinue dance because of lifestyle transitions was 78.6%, with 57.6% returning to the preinjury performance level or a higher level. Higher femoral head Outerbridge grade was found to be a predictor of secondary surgical procedures.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Capsular Management During Hip Arthroscopy Is Recommended, But a Limited Capsulotomy in Male Patients May Heal Without Closure

The hip capsule consists of the iliofemoral, ischiofemoral, and pubfemoral ligaments. The iliofemoral ligament is an important part of the anterior hip capsule that functions to stabilize the joint but is commonly incised in order to obtain access during hip arthroscopy, as described in techniques such as interportal, T, puncture, and periportal capsulotomy. For the most commonly used interportal capsulotomy, recent literature has advocated for closure of the capsule at the end of the surgery to avoid iatrogenic instability or microinstability. Systematic reviews and cohort studies have reported significantly better patient-reported outcomes after hip arthroscopy for femoroacetabular impingement syndrome with capsule closure compared to without capsule closure. However, recent high-level evidence from a randomized controlled trial demonstrated that in a predominantly male cohort there was no difference in patient-reported outcomes improvements or complications between patients undergoing hip arthroscopy for femoroacetabular impingement syndrome through an interportal capsulotomy who were randomized to receive capsule closure versus no capsule closure. Of note, male patients have inherently tighter and more stable joints than female patients and therefore are at lower risk for postoperative instability or microinstability from an interportal capsulotomy that does not properly heal. Also, if the capsule is not violated below the 3-o'clock position (for a right hip, or 9 o'clock for a left hip), there may be less risk to destabilizing the hip joint. A limited interportal capsulotomy in male patients could lead to healing in an unrepaired state.

Capsular Management During Hip Arthroscopy

PURPOSE OF REVIEW

Hip arthroscopy is widely used for the management of intra-articular pathology and there has been growing interest in strategies for management of the hip capsule during surgery. The hip capsule is an essential structure that provides stability to the joint and it is necessarily violated during procedures that address intra-articular pathology. This article reviews different approaches to capsular management during hip arthroscopy including anatomical considerations for capsulotomy, techniques, clinical outcomes, and the role of routine capsular repair. This article also reviews the concept of hip microinstability and its potential impact on capsular management options as well as iatrogenic complications that can occur as a result of poor capsular management.

RECENT FINDINGS

Current research highlights the key functional role of the hip capsule and the importance of preserving its anatomy during surgery. Capsulotomies that involve less tissue violation (periportal and puncture-type approaches) do not appear to require routine capsular repair to achieve good outcomes. Many studies have investigated the role of capsular repair following more extensive capsulotomy types (interportal and T-type), with most authors reporting superior outcomes with routine capsular repair. Strategies for capsular management during hip arthroscopy range from conservative capsulotomy techniques aimed to minimize capsular violation to more extensive capsulotomies with routine capsule closure, all of which have good short- to mid-term outcomes. There is a growing trend towards decreasing iatrogenic capsular tissue injury when possible and fully repairing the capsule when larger capsulotomies are utilized. Future research may reveal that patients with microinstability may require a more specific approach to capsular management.

Outcomes After Concomitant Hip Arthroscopy and Periacetabular Osteotomy: A Systematic Review

Background

Despite several studies' reports on outcomes of concomitant hip arthroscopy and periacetabular osteotomy (PAO), there is a paucity of aggregate data in the literature.

Purpose

To evaluate outcomes and survivorship after concomitant hip arthroscopy and PAO.

Study Design

Systematic review; Level of evidence, 4.

Methods

The PubMed, Cochrane, and Scopus databases were searched in April 2022 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The following keywords were used: (hip OR femoroacetabular impingement) AND (arthroscopy OR arthroscopic) AND (periacetabular osteotomy or rotational osteotomy) AND (outcomes OR follow-up). Of 270 articles initially identified, 10 studies were ultimately included. The following information was recorded for each study if available: publication information; study design; study period; patient characteristics; follow-up time; indications for hip arthroscopy; patient-reported outcomes (PROs); rates of secondary hip preservation surgeries; and rates of conversion to total hip arthroplasty (THA). Survivorship was defined as nonconversion to THA.

Results

The study periods for the 10 included articles ranged from 2001 to 2018. Three studies were level 3 evidence, and 7 studies were level 4 evidence. This review included 553 hips with a mean follow-up of 1 to 12.8 years. All 10 studies listed dysplasia as an indication for surgery. Of 9 studies that reported PRO scores, 7 reported significant improvement after surgery. Studies with a <5-year follow-up reported conversion to THA rates of 0% to 3.4% and overall secondary surgery rates of 0% to 10.3%. Similarly, studies with >5-year follow-up reported conversion to THA rates of 0% to 3% and overall secondary surgery rates of 0% to 10%.

Conclusion

Patients who underwent concomitant hip arthroscopy and PAO reported favorable outcomes, with 7 of the 9 studies that provided PRO scores indicating significant preoperative to postoperative improvement.

Editorial Commentary: The Importance of Capsular Closure Following Hip Arthroscopy-Leave No Trace: An Outdoorsman's Ramblings

After a decade-long paradigm shift and an evidence-based enormous increase in the prevalence of hip arthroscopic procedures, hip capsular closure following arthroscopy, once a rare procedure, is now performed in the majority of surgical cases. This results from improved surgeon experience, refined surgical technologies and techniques and an explosion of research regarding stability of the hip joint. Once viewed as inherently stable, it is become clear that meticulous capsular management and closure can not only maintain joint stability but is a treatment for and/or prevents micro-instability. Recent research shows that hip capsular closure can improve outcomes and return to sport rates in the highest demand athletes having hip arthroscopy. Close the capsule!