No association between femoral or acetabular angles and patient-reported outcomes in patients with femoroacetabular impingement syndrome-results from the HAFAI cohort

Effect of cam resection depth on clinical outcomes after primary hip arthroscopy

BACKGROUND

The amount of resection or the starting point of the resection on the femoral head for cam lesions in femoroacetabular impingement (FAI) is controversial.

AIM

The purpose of this study was to study the effect of postoperative resection depth, and resection arc ratio of cam lesion on the frequency of achieving substantial clinical benefit (SCB), patient acceptable state (PASS) in modified Harris Hip Score (mHHS) and Hip Outcome Score Activity of Daily Living (HOSADL), 2 years postoperatively.

PATIENTS AND METHODS

All patients who underwent first-time hip arthroscopy for FAI with a 2-year follow-up were included in this study. Patient-reported outcomes included the mHHS, HOSADL, and visual analogue scale for pain (Pain VAS). Radiological parameters such as alpha angletraditional (αT), alpha anglecartilage (αC), resection arc ratio (% alpha anglecartilage-alpha angletraditional/360°), resection depth (''D''mm) and resection depth ratio 'D%' (D/femoral head diameter %) were measured using the 45° Dunn view.

RESULTS

We identified 26 patients (27 hips) with 2-year follow-up. There were 10 female and 16 male patients. The mean age of the patients was 33 ± 12 years.Higher frequency of achieving SCB threshold for mHHS was related to labrum repair (73% vs. debridement '27%' p = 0.03), lower preoperative αT (64° vs. 76°, p = 0.04), lower preoperative mHHS (54 vs. 81, p < 0.001) and higher preoperative VAS scores (8 vs. 7, p = 0.02). Higher frequency of reaching PASS threshold for mHHS was associated with lower αC (82°vs. 92° p:0.02), lower RA (8% vs. 11%, p = 0.03), lower D (2.8 mm vs. 4.5 mm p:0.03), lower D% (4.7% vs. 8.4% p = 0.04) and higher postoperative mHHS (97 vs. 82 p < 0.001).

CONCLUSIONS

A higher frequency of achieving SCB for HOSADL was related to lower D% (5% vs. 10.5%, p = 0.04).Cam resection depth affects the frequency of achieving clinically meaningful scores and resection depth less than 6% of the femoral head diameter seems to be appropriate for optimal results. The starting point of resection on head cartilage needs to be <90° when alpha angle is used for reference.

Postoperative alpha angle seems to be important for the achievement of clinical significance at a minimum 5-year follow-up after primary hip arthroscopy

The purpose of the present study was to clarify whether there is an association of postoperative alpha value with functional scores or progression of osteoarthritis at X-rays at the midterm after arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair or debridement and rim trimming. A retrospective review of prospectively gathered data from 2013 to 2017 was performed. All patients who underwent first-time unilateral hip arthroscopy for FAI resection with 5-year follow-up were included. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). The progression of osteoarthritis (Tönnis grade) and radiological parameters (alpha angle, lateral center-edge angle [LCEA] and head-neck offset) were evaluated. A receiver operating characteristic (ROC) analysis was used to evaluate the correlation between significant variables and achievement of patient-acceptable symptomatic state (PASS) and degree of osteoarthritis. We identified 52 patients with a minimum 5-year follow-up (average, 6.7 years). The average patient age was 33.9 ± 11.5 years. There were 19 (36.5%) female patients. The mHHS improved from 60.1 ± 13.4 before surgery to 86.8 ± 14 after surgery (P < 0.001). The Pain VAS decreased from 6.21 before surgery to 2 after surgery (P < 0.001). Overall, 69% achieved the PASS for mHHS. The ROC curve for postoperative alpha angle demonstrated acceptable discrimination between patients achieving a fifth-year PASS value and those who did not have an area under the curve of 0.72. Patients having a postoperative alpha angle of ≤48.3° achieved the fifth-year PASS value at a significantly higher rate than patients having a postoperative alpha angle of >48.3° (P = 0.002). The postoperative alpha angle is a predictor of the achievement of the fifth-year PASS value for the mHHS. A threshold of ≤48.3° had a sensitivity of 0.75 and a specificity of 0.69 to predict positivity. Level of evidence IV.

Does femoroacetabular impingement syndrome affect range of motion? A systematic review with meta-analysis

BACKGROUND

It is unclear whether femoroacetabular impingement syndrome (FAIS) affect hip range of motion (ROM).

SOURCES OF DATA

We performed a systematic review with meta-analysis searching six electronic databases from inception to March 21, 2022. We included studies assessing hip ROM in FAIS, FAI morphology without symptoms (FAIm), and healthy controls. Mean differences between groups were measured in ROM degrees with 95% confidence interval (CI).

AREAS OF AGREEMENT

A total of 17 studies (1702 hips) were included. Comparison of FAIS patients versus healthy controls showed that hip ROM was clinically and statistically reduced in FAIS for internal rotation (90° hip flexion, -8.01°, 95% CI: -11.21, -4.90; 0° hip flexion -6.38°, 95% CI: -9.79, -2.97); adduction (90° hip flexion, -4.74°, 95% CI: -8.13, -1.34); flexion (-5.41°, 95% CI: -7.05, -3.49), abduction (0° hip flexion, -5.76°, 95% CI: -8.38, -3.23), and external rotation (90° hip flexion, -3.5°, 95% CI: -5.32, -1.67) ranging from low to high certainty of evidence. Comparison of FAIm versus healthy controls showed no statistically significant differences in any direction of movement, albeit with uncertainty of evidence.

AREAS OF CONTROVERSY

The certainty of evidence was unclear, particularly for asymptomatic FAIm.

GROWING POINTS

Hip ROM may be reduced in all directions except extension in FAIS compared to controls. Hip ROM may not be restricted in asymptomatic FAIm.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further studies are needed to resolve the uncertainty of evidence about ROM restrictions in asymptomatic FAIm compared to healthy controls.

Femoral Version May Impact Hip Arthroscopy Outcomes in Select Patient Populations: A Systematic Review

PURPOSE

To provide further clarity regarding the management of patients with abnormal femoral version in the setting of hip arthroscopy and will discuss the definition of femoral version, the diagnostic and clinical evaluation of abnormal femoral version, and several described measurement techniques.

METHODS

A systematic review was conducted in literature published before August 2021 that measured femoral version and reported patient-reported outcomes measures or rates of subsequent procedures following hip arthroscopy. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed and the electronic databases, PubMed, OvidMedLine, Scopus, and Web of Science were searched. Two blinded reviews screened and evaluated data quality using the Newcastle-Ottawa Scale.

RESULTS

Eighteen studies were included with 11 studies reporting patient outcomes and 7 studies reporting rates of subsequent procedures. The most commonly used definition of femoral version was 5° to 20° of femoral anteversion. Computed tomography scan was the most commonly used imaging modality. The majority of studies (7 of 11) demonstrated that femoral version does not have an impact on patient-reported outcomes measures and is not predictive of clinically meaningful improvement scores. However, in select studies, patients with femoral retroversion were found to experience slightly inferior outcomes following hip arthroscopy for femoroacetabular impingement. While femoral retroversion may be a risk factor for subsequent procedures, 3 of 7 studies refute this claim. Although in patients with borderline hip dysplasia, excessive femoral anteversion led to greater rates of subsequent hip procedures.

CONCLUSIONS

While the majority of studies show that femoral version does not have an impact on patient-reported outcomes following hip arthroscopy, those with femoral retroversion and with excessive anteversion with coexisting borderline hip dysplasia need to be educated on their increased risk of subsequent operation. Ultimately, this review suggests that clinical improvement can likely be achieved regardless of femoral version.

LEVEL OF EVIDENCE

IV; systematic review of Level I-IV studies.

Five-Year Follow-up After Hip Arthroscopic Surgery in the Horsens-Aarhus Femoroacetabular Impingement (HAFAI) Cohort

Background:

Patients with femoroacetabular impingement syndrome (FAIS) are offered hip arthroscopic surgery to decrease hip pain, improve their function, and decrease development of hip osteoarthritis (OA). Nonetheless, long-term follow-up data are few.

Purpose:

To investigate patient-reported outcomes, clinical tests, reoperations, and radiographic status 5 years after primary hip arthroscopy in patients with FAIS.

Study Design:

Case series; Level of evidence, 4.

Methods:

A total of 60 patients (age, 36 ± 9 years; 63% female) diagnosed with FAIS were included in the study and followed for 5 years after hip arthroscopy. Follow-up included Copenhagen Hip and Groin Outcome Score (HAGOS); Hip Sports Activity Scale; and clinical tests (flexion, adduction, internal rotation [FADIR]; flexion, abduction, external rotation [FABER]; and psoas muscle/tendon major pain provocation). Radiographic evaluation included lateral joint-space width (LJSW) and Tönnis classification for hip OA. Reoperations and conversion to total hip replacement (THR) were recorded. We calculated the proportion of patients who exceeded the minimal important change (MIC), achieved the Patient Acceptable Symptom State (PASS), and were within the 95% reference interval of age- and sex-matched persons with no hip problems. Changes were investigated using paired t tests.

Results:

Compared with preoperatively, all HAGOS subscales were improved substantially 5 years after surgery (mean, ≥21 points; P < .001), and 67% to 89% of patients reported improvements exceeding MIC. Between 56% and 80% achieved PASS, but only 7% to 24% reached the 95% reference interval for the HAGOS subscales. A total of 36% had a positive FADIR test and 25% had a positive FABER test, which were improvements compared with preoperatively (P < .001 for both). Patients with a positive FADIR test had significantly worse HAGOS subscales. Six patients (10%) had a THR since their primary hip arthroscopy. In the remaining patients, the mean LJSW was decreased (-0.4 mm; P = .043), and hip OA had worsened in 9 patients (23%; P = .003).

Conclusion:

Five years after surgery, the majority of patients experienced HAGOS improvements exceeding MIC while also showing an acceptable PASS. However, clinical tests, participation in physical activities, and quality of life indicated that many patients still experience hip problems.

Registration:

NCT04590924 (ClinicalTrials.gov identifier).

Are cam morphology size and location associated with self‐reported burden in football players with FAI syndrome?

Cam morphology size and location might affect the severity of reported burden in people with femoroacetabular impingement (FAI) syndrome. We investigated the relationship between cam morphology size (i.e., alpha angle) and self‐reported hip/groin burden (i.e., scores for the International Hip Outcome Tool‐33 (iHOT‐33) and Copenhagen Hip and Groin Outcome Score (HAGOS)), examined separately for the anteroposterior pelvis (AP) and Dunn 45° radiographs in football players with FAI syndrome. In total, 118 (12 women) subelite football (soccer or Australian football) players with FAI syndrome with cam morphology (alpha angle ≥60°) participated. One blinded assessor quantified superior and anterosuperior cam morphology size by measuring alpha angles for the AP and Dunn 45° radiographs, respectively. Linear regression models investigated relationships between alpha angle (continuous independent variable, separately measured for the AP and Dunn 45° radiographs) and iHOT‐33 and HAGOS scores (dependent variables). Larger anterosuperior cam morphology (seen on the Dunn 45° radiograph) was associated with lower (i.e., worse) scores for the iHOT‐Total, iHOT‐Symptoms, iHOT‐Job, and iHOT‐Social subscales (unadjusted estimate range −0.553 to −0.319 [95% confidence interval −0.900 to −0.037], p = 0.002 to 0.027), but not the iHOT‐Sport (p = 0.459) nor any HAGOS scores (p = 0.110 to 0.802). Superior cam morphology size (measured using the AP radiograph) was not associated with any iHOT‐33 or HAGOS scores (p = 0.085 to 0.975). Larger anterosuperior cam morphology may be more relevant to pain and symptoms in football players with FAI syndrome than superior cam morphology, warranting investigation of its effects on reported burden and hip disease over time.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF)

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

There is no definite consensus on the adequate radiographic correction in arthroscopic osteochondroplasty for femoroacetabular impingement: a systematic review and meta-analysis

PURPOSE

The purpose of this study is to evaluate and define what is considered an adequate radiographic correction in arthroscopic osteochondroplasty for FAI and to secondarily assess how radiographic outcomes relate to patient reported outcomes and complications.

METHODS

The databases EMBASE, PubMed, and MEDLINE were searched for relevant literature from database inception until January 2021. Studies were screened by two reviewers independently and in duplicate for studies reporting on post-operative radiographic outcomes in arthroscopic osteochondroplasty for FAI. Data on radiographic outcomes as well as data reporting functional outcomes and complications were recorded. A meta-analysis was used to combine the mean pre- and post-operative radiographic outcomes using a random effects model. A risk of bias assessment was performed for all included studies using the MINORS score.

RESULTS

The most commonly reported radiographic outcome was the alpha angle with a pooled mean post-operative angle of 44° (95% CI 41°-46°), and mean pre- to post-surgical difference of - 19° (- 22 to - 16, I² = 96%), followed by the LCEA with a pooled mean post-operative angle of 30° (95% CI 29-31) and mean difference after surgery of - 4° (- 6 to - 1, I² = 97%,). Eleven studies reported on the correlation between radiographic and clinical outcomes with no consistent consensus correlation found amongst the included studies. Similarly, six studies correlated radiographic outcomes with conversion to THA with no consistent consensus correlation found amongst the included studies.

CONCLUSION

Based on this review, the main conclusion is that there is no consensus definition on the optimal radiographic correction for FAI and there was no consistent correlation between radiographic correction and functional outcomes. However, based on the uniform improvement in functional outcomes, this review suggests a post-operative alpha angle target of 44° with a correction target of 19° and LCEA target of 30° with a correction target of 3°.

LEVEL OF EVIDENCE

IV.

The Association of α Angle on Disease Severity in Adolescent Femoroacetabular Impingement

BACKGROUND

Femoroacetabular Impingement (FAI) is a common cause of hip pain in adolescent patients. Clinical exam and radiographic markers, such as α angle and lateral center edge angle (LCEA), are commonly used to aid in the diagnosis of this condition. The purpose of this study was to correlate preoperative α angle and LCEA with preoperative symptoms, intraoperative findings, and preoperative and postoperative patient reported outcomes (PROs) in the adolescent patient.

METHODS

A retrospective analysis of prospectively collected data was conducted for all patients who underwent operative intervention for FAI at an academic institution over an 11-year period. Preoperative imaging was obtained and measured for LCEA and α angle. PROs (modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA score) were collected preoperatively, as well as 1, 2, and 5 years postoperatively. Operative intervention was either open surgical hip dislocation or arthroscopic, and intraoperative disease was graded using the Beck Classification system. Patients with minimum 1-year follow-up were included in statistical analysis.

RESULTS

There were 86 hips (64 female hips) included with an average age of 16.3 years (range, 10.4 to 20.5 y), with an average of 37 months of follow-up. There was no correlation between severity of preoperative symptoms or difference between pre and postoperative PROs for both α angle and LCEA. Overall, significant improvement was noted in modified Harris Hip Score, Hip Disability and Osteoarthritis Outcome Score, and UCLA Score (P<0.001 for each). Independent of preoperative symptoms, increased α angle correlated with more severe intraoperative labral disease (P<0.001), and longer length of labral tear (Corr 0.295, P<0.01). Femoral head and acetabular articular cartilage damage did not correlate with α angle or LCEA, nor did overall severity of disease.

CONCLUSIONS

In adolescent patients with FAI, increased α angle was found to significantly correlate with labral pathology, including increased length of tear and severity of disease, irrespective of preoperative symptoms or postoperative patient reported outcomes.

LEVEL OF EVIDENCE

Level III-retrospective.