Refractory pain following hip arthroscopy: evaluation and management

Comparison of the Effect of Pericapsular Nerve Group Block Combined with Lateral Femoral Cutaneous Nerve Block and Fascia Iliaca Compartment Block in Patients Undergoing Hip Arthroscopy Under General Anesthesia: A Randomized, Double-Blind Trial

Purpose

Patients undergoing arthroscopic hip surgery (AHS) require good analgesia and early rehabilitation after surgery, and there is no consensus on the optimal nerve block. We aimed to compare the efficacy of the pericapsular nerve group (PENG) block with lateral femoral cutaneous nerve (LFCN) block compared to fascia iliaca compartment block (FICB) in patients with AHS.

Patients and Methods

A total of 80 patients receiving AHS under general anesthesia were randomized to receive either FICB (group F) or PENG block in combination with LFCN block (group P). The primary outcomes were the rate of quadriceps weakness after block on the afflicted side, as well as muscle strength grading and pain score after block, and the quality of recovery on the second postoperative day.

Results

Compared with group F, group P had a lower incidence of quadriceps weakness 48 h after block (76.9% vs 28.2%, P < 0.001), and had less impact on muscle strength grade and lower static pain score at 6, 12, 18, 24, 36, and 48 h after block (P < 0.001), and a lower dynamic pain score at 6 and 12 h after block in group P (p < 0.05). The quality of recovery on the second postoperative day improved (p < 0.05).

Conclusion

In comparison to FICB, PENG block in combination with LFCN block can affect less quadriceps muscle strength and reduce the use of postoperative analgesics, which is beneficial for the postoperative recovery of AHS patients.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

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

PREHAB FAI- Prehabilitation for patients undergoing arthroscopic hip surgery for Femoroacetabular Impingement Syndrome -Protocol for an assessor blinded randomised controlled feasibility study

BACKGROUND

The past decade has seen an exponential growth of minimally invasive surgical procedures. Procedures such as hip arthroscopy have rapidly grown and become the standard of care for patients with Femoroacetabular Impingement Syndrome (FAIS). Although, the results of such procedures are encouraging, a large proportion of patients do not achieve optimal outcomes due to chronicity and deconditioning as a result of delay in diagnosis and increased waiting times amongst other factors. In a recent systematic review and meta-analysis of randomised control trials, moderate certainty evidence supported prehabilitation over standard care in optimising several domains including muscle strength, pain and health related quality of life in patients undergoing orthopaedic surgical interventions. However, the role of prehabilitation in patients with FAI syndrome undergoing hip arthroscopy has received little attention.

AIM

To evaluate the feasibility, suitability, acceptability and safety of a prehabilitation programme for FAI to inform a future definitive randomised control trial to assess effectiveness.

METHODS

A systematically developed prehabilitation intervention based on a literature review and international consensus will be utilised in this study. A mixed methodology encompassing a two-arm randomised parallel study alongside an embedded qualitative component will be used to answer the study objectives. Patients will be recruited from a tertiary referral NHS centre for young adult hip pathology in the UK. Patient reported outcomes such as iHOT-12, Brief Pain Inventory Scale (Short form), Hospital Anxiety and Depression Scale and Patient Global Impression of Change score will be obtained alongside objective measurements such as Muscle Strength and Star Excursion Balance Test at various time points. Outcome measures will be obtained at baseline (prior to prehabilitation intervention), after prehabilitation before surgery, and at 6 weeks+/- 4 weeks and 6 months +/- 4 weeks (planned primary endpoint for definitive RCT) postoperatively when participants attend the research site for clinical care and remotely at 12 months +/- 4 weeks postoperatively. Mean change and 95% CI, and effect size of outcome measures will be used to determine the sample size for a future RCT. For the qualitative component, in depth face-to-face semi-structured interviews with physiotherapists and focus groups with participants will be conducted to assess the feasibility, suitability, and acceptability of the prehabilitation intervention using a predetermined success criteria. All qualitative data will be recorded, transcribed verbatim and thematically analysed.

DISCUSSION

This study will be first of its kind to evaluate a systematically developed prehabilitation intervention for patients with FAIS undergoing hip arthroscopy. This study will provide important preliminary data to inform feasibility of a definitive RCT in the future to evaluate effectiveness of a prehabilitation intervention.

TRIAL REGISTRATION

ISRCTN 15371248, 09/03/2023.

TRIAL PROTOCOL

Version 2.3, 26th June 2023.

The Incidence and Outcomes Following Treatment of Capsulolabral Adhesions in Hip Arthroscopy: A Systematic Review

Background

To perform a systematic review to evaluate the incidence of capsulolabral adhesions following hip arthroscopy (HA) for femoroacetabular impingement (FAI); including risk factors and post-treatment outcomes.

Methods

Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we queried PubMed, EMBASE, and Cochrane Central Register of Controlled Trials for English-language studies with minimum 6-month follow-up after primary or revision HA for FAI, which reported the incidence of capsulolabral adhesions. Potential adhesion risk factors, such as anchor type used and protocol for capsule closure, were assessed. Pre-operative and post-operative modified Harris Hip Score (mHHS) values were compared in studies that reported them.

Results

Thirty-seven articles were included (24 primary HA; 13 revision HA). There were 6747 patients who underwent primary HA (6874 hips; 3005 female, 44%). The incidence of capsulolabral adhesions, confirmed surgically during revision HA, was low. Patients undergoing surgical treatment reported postoperative improvement per modified Harris Hip Scores. Data for 746 patients undergoing second revision HA (761 hips; 449 female, 60%), showed an incidence of adhesions greater than that of primary HA patients.

Conclusion

While the incidence of symptomatic capsulolabral adhesions after primary hip arthroscopy is low; revision hip arthroscopy is strongly associated with adhesion development. Lysis of adhesions in primary hip arthroscopy patients reliably improved patient-reported outcomes. Level of Evidence: IV.

Adhesions in the setting of hip arthroscopy

With the growing number of primary arthroscopies performed, patients requiring revision hip arthroscopies for various issues is high including postoperative adhesion formation, a source of pain, mechanical symptoms, range of motion limitation, stiffness, and microinstability. Adhesions are a consequence of biological pathways that have been stimulated by injury or surgical interventions leading to an increased healing response. Preventative efforts have included surgical adjuncts during/after primary hip arthroscopy, biologic augmentation, and postoperative rehabilitation. Treatment options for adhesion formation includes surgical lysis of adhesions with or without placement of biologic membranes aimed at inhibiting adhesion reformation as well as systemic medications to further reduce the risk. Postoperative rehabilitation exercises have also been demonstrated to prevent adhesions as a result of hip arthroscopy. Ongoing clinical trials are further investigating pathways and prevention of adhesion formation.

Outcomes for Treatment of Capsulolabral Adhesions With a Capsular Spacer During Revision Hip Arthroscopy

BACKGROUND

The presence of adhesions is a common source of pain and dysfunction after hip arthroscopic surgery and an indication for revision surgery. The placement of a capsular spacer in the capsulolabral recess after lysis of adhesions has been developed to treat and prevent the recurrence of adhesions.

PURPOSE

To evaluate patient-reported outcomes (PROs) and survivorship at a minimum of 2 years after revision hip arthroscopic surgery with capsular spacer placement for capsular adhesions.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between January 2013 and June 2018, a total of 95 patients (99 hips) aged ≥18 years underwent revision hip arthroscopic surgery for the treatment of capsular adhesions with the placement of a capsular spacer. Overall, 53 patients (56 hips) met the inclusion criteria and had a minimum 2-year follow-up, forming the cohort of this study. Exclusion criteria included confounding metabolic bone diseases (eg, Legg-Calve-Perthes disease, Marfan syndrome), labral deficiency, or advanced osteoarthritis (Tönnis grade 2 or 3). Preoperative and postoperative outcome scores (modified Harris Hip Score [mHHS], Hip Outcome Score-Activities of Daily Living [HOS-ADL], Hip Outcome Score-Sport-Specific Subscale [HOS-SSS], 12-Item Short Form Health Survey [SF-12], and Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) were collected and compared in addition to the revision rate, conversion to total hip arthroplasty, and patient satisfaction.

RESULTS

The mean age of the cohort was 32 ± 11 years, with 32 female hips (57%) and a median number of previous hip arthroscopic procedures of 1 (range, 1-5). The arthroplasty- and revision-free survivorship rate at 2 years was 91%. Overall, 5 patients (6 hips; 11%) underwent revision surgery at a mean of 2.4 ± 1.4 years after capsular spacer placement, with symptomatic capsular defects being the most common finding. There were 4 patients (7%) who converted to total hip arthroplasty. For hips not requiring subsequent surgery (n = 46), there was a significant improvement in outcome scores except for the SF-12 Mental Component Summary, with rates of achieving the minimal clinically important difference of 70%, 70%, and 65% for the mHHS, HOS-ADL, and HOS-SSS, respectively.

CONCLUSION

Capsular spacers, as part of a systematic approach including lysis of adhesions with early and consistent postoperative physical therapy including circumduction exercises, resulted in improved PROs as well as high arthroplasty- and revision-free survivorship (91%) at a minimum 2-year follow-up. Capsular spacers should be considered in revision hip arthroscopic procedures when an adequate labral volume remains but adhesions continue to be a concern.

Periacetabular osteotomy after failed hip arthroscopy demonstrates improved outcomes in a heterogenous patient population: a systematic review

PURPOSE

To evaluate the literature on patients undergoing periacetabular osteotomy after failed hip arthroscopy (PAO-FHA) for (1) patient demographics and hip morphology, (2) changes in preoperative to postoperative patient-reported outcomes (PROs), and (3) PROs in comparison to primary periacetabular osteotomy (PAO) patients.

METHODS

A systematic literature search of Pubmed, CINAHL/Medline, and cochrane databases was performed in accordance with PRISMA guidelines. The search phrase was "(periacetabular osteotomy or PAO or rotational osteotomy) and (hip arthroscopy or arthroscopic)". The titles, abstracts, and full texts were screened for studies on PAO-FHA. Study quality was assessed, and relevant data were collected. A meta-analysis was not performed due to study heterogeneity.

RESULTS

The search identified 7 studies, including 151 hips (148 patients, 93.9% female) undergoing PAO-FHA, out of an initial 593 studies, with three Level IV and four Level III studies. Mean time from hip arthroscopy to PAO ranged from 17.0 to 29.6 months. Heterogenous hip morphologies and radiologic findings prior to PAO were observed, though patients most frequently demonstrated moderate-to-severe dysplasia (mean or median lateral center edge angle < 20°) and minimal osteoarthritis (Tönnis grade 0 or 1). In all 5 studies that reported concomitant procedures with PAO, femoral and/or acetabular osteoplasty was performed via arthroscopy or arthrotomy. Following PAO-FHA, radiographic acetabular coverage and PROs improved in all 6 studies that reported postoperative outcomes. All four comparative studies of primary PAO vs. PAO-FHA included patients with mean or median LCEAs < 20°, reporting mixed outcomes for the optimal treatment approach.

CONCLUSION

PAO-FHA is reported in a heterogenous patient population that frequently includes hips with moderate-to-severe dysplasia and minimal osteoarthritis. Regardless of hip morphology or concomitant procedures, all studies that reported postoperative outcomes demonstrated improved PROs following PAO-FHA.

LEVEL OF EVIDENCE

Level IV.

Peripheral Nerve Block for Hip Arthroscopy Does Not Have any Clinical Advantage Compared With Local Anesthetic Regarding Pain Management: A Meta-analysis of Randomized Controlled Trials

PURPOSE

To evaluate the efficacy of peripheral nerve block on reduction in opioid consumption and pain control after hip arthroscopy.

METHOD

To identify studies evaluating the effects of peripheral nerve block on pain control and reduction in opioid consumption in hip arthroscopy, we searched all records in the PubMed, Embase, and Cochrane Library databases until May 2021. Studies with the following characteristics were considered eligible: 1) patients who underwent a hip arthroscopy (population); 2) patients who received peripheral nerve block (intervention); 3) patients who did not receive peripheral nerve block (comparator); 4) record of total opioid consumption as a primary outcome and pain level at 1, 3 to 6, and 24 hours after surgery, patient satisfaction, and incidence of nausea and vomiting as secondary outcomes (outcomes); and 5) randomized controlled trial (study design). Data were independently extracted by two reviewers and synthesized using a random or fixed-effects model, according to the heterogeneity.

RESULTS

Eight RCTs were finally included in the meta-analysis. There were no significant differences in postoperative opioid consumption at 24 hours (standardized mean difference [SMD] = -0.091, 95% confidence interval [CI] [-0.270, 0.089]) or in visual analog scale (VAS) score at 1 (SMD = 0.299, 95% CI [-0.758, 0.160]), 3 to 6 (SMD = -0.304, 95% CI [-0.655, 0.047]), and 24 (SMD = -0.230, 95% CI [-0.520, 0.060]) hours postoperatively between the peripheral nerve block and control groups. Moreover, no significant differences were observed in patient satisfaction (SMD < 0.001, 95% CI [-0.284, 0.284]) or the incidence of nausea and vomiting (SMD = 0.808, 95% CI [0.311, 2.104]) between the two groups.

CONCLUSION

Peripheral nerve block for hip arthroscopy has no clinical advantage regarding pain management after surgery when compared with the group that received the local infiltration of analgesics without peripheral nerve block.

LEVEL OF EVIDENCE

Level II, meta-analysis of level I and II randomized controlled trials (RCTs).

Three-Dimensional Magnetic Resonance Arthrography of Post-Arthroscopy Hip Instability Demonstrates Increased Effective Intracapsular Volume and Anterosuperior Capsular Changes

Purpose

To quantify the magnetic resonance arthrography (MRA) capsular morphologic findings associated with postarthroscopy hip instability.

Methods

Among patients with clinically significant iatrogenic hip instability at a single center, patients with preindex and postindex surgery MRAs were identified. These MRAs were compared regarding effective intracapsular volume calculated by semi-automated 3-dimensional pixel intensity region segmentation, 2-dimensional anterior proximal intracapsular area in the femoral neck axial plane reconstruction, maximal anterior fluid pocket depth, capsule retraction distance, and capsular instability grade. Morphological measurements were conducted using Horos image processing software. Paired t-test, paired Wilcoxon signed rank test, and the McNemar test were used for identifying statistical significance.

Results

In 42 patients, mean effective intracapsular volume was significantly greater in the postindex surgery MRAs (19.44 cm³ vs 17.26 cm³; P = .006). Proximal anterosuperior (12-3 o'clock) intracapsular area was also significantly greater after index surgery (2.84 cm² vs 1.43 cm²; P < .001. Proximal anteroinferior (3-6 o'clock) intracapsular area (1.34 cm² vs 0.97 cm²; P = .002), capsule deficiency grade (P < .001), anterior capsule retraction distance (4.83 mm vs 0.34 mm; P < .001), and maximum anterior fluid depth (8.33 mm vs 4.90 mm; P <.001) were also significantly increased after index surgery.

Conclusion

In comparison to the preoperative state, iatrogenic hip instability is associated with MRA findings that include increases in total effective intracapsular volume, proximal anterosuperior and anteroinferior intracapsular cross-sectional area, maximum proximal anterosuperior fluid depth, and capsule retraction distance.

Level of Evidence

Level IV, diagnostic case series.

Failure to Achieve Threshold Scores on Patient-Reported Outcome Measures Within 1 Year Has a Predictive Risk of Subsequent Hip Surgery Within 5 Years of Primary Hip Arthroscopy: A Case-Control Study

Background:

Research has identified factors that influence achievement rates of threshold scores on patient-reported outcome measures (PROMs) after hip arthroscopy. However, little data exist on whether failure to achieve a threshold score (minimal clinically important difference [MCID] or substantial clinical benefit [SCB]) in the short term after hip arthroscopy predicts the risk of future hip surgery.

Purpose/Hypothesis:

The purpose of this study was to determine if failure to achieve the MCID or SCB on PROMs within 1 year of hip arthroscopy can be considered a risk factor for repeat surgery within 5 years of primary hip arthroscopy. It was hypothesized that failure to achieve threshold scores would increase the risk of subsequent hip surgery.

Study Design:

Case-control study; Level of evidence, 3.

Methods:

A retrospective review of prospectively collected data was completed. Four PROMs were collected preoperatively and within 1 year of hip arthroscopy: modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, Hip Outcome Score–Sports, and the 33-Item International Hip Outcome Tool.

Results:

Two cohorts were formed: (1) a study cohort (n = 88) composed of patients who underwent repeat hip surgery within 5 years of hip arthroscopy and (2) a control cohort (n = 288) composed of patients who did not require repeat hip surgery. The study cohort had significantly (P < .001) lower scores on all postoperative PROMs, and a significantly (P < .001) smaller percentage of the study cohort met the MCID and SCB. Multivariable regression analysis demonstrated that not achieving the MCID or SCB on each of the PROMs is an independent risk factor for repeat hip surgery. For every PROM in which a patient failed to achieve the MCID, the odds of subsequent surgery increased by 1.68 (95% CI, 1.42-1.98; P < .001). For every PROM in which a patient failed to achieve the SCB, the odds of subsequent surgery increased by 1.63 (95% CI, 1.35-1.97; P < .001).

Conclusion:

Failure to meet threshold scores on PROMs after hip arthroscopy was an independent risk factor for subsequent hip surgery. This study establishes a novel utility of PROMs and confirms the importance of these metrics in the orthopaedic literature.

Autograft Versus Allograft: The Evidence in Hip Labral Reconstruction and Augmentation

BACKGROUND

Labral augmentation and labral reconstruction have emerged as essential procedures for restoring the anatomic and functional characteristics of the hip joint in patients with a deficient hip labrum or irreparable labral tear.

HYPOTHESIS/PURPOSE

The purpose of this study was to compare allograft and autograft hip labral reconstruction and augmentation. We hypothesized that autografts would entail fewer revision arthroscopic procedures.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were identified who underwent labral reconstruction or labral augmentation using iliotibial band (ITB) allograft or ITB autograft performed by a single surgeon between 2011 and 2017. Patient-reported outcome measures collected before surgery and at minimum 2-year follow-up included the following: Hip Outcome Score Activities of Daily Living and Hip Outcome Score Sports-Specific Subscale and, at follow-up, patient satisfaction (range, 1-10, with 10 being very satisfied). Patients followed a standardized rehabilitation protocol after surgery with relative individualization to address each patient's needs. For continuous variables, comparisons between allografts and autografts were made using Student t tests or Mann-Whitney tests. Categorical comparisons were assessed using chi-square or Fisher exact test. Multiple logistic regression was performed to determine the influence of graft choice on risk of revision or THA.

RESULTS

A total of 205 hips met 2-year inclusion criteria. ITB allografts were used for 55 patients (37 augmentations, 18 reconstructions) and ITB autografts for 150 patients (34 augmentations, 116 reconstructions). Females represented a greater proportion of allograft versus autograft patients (71% vs 46%, respectively; P = .001). Overall, autograft patients had larger alpha angles (66.6° vs 59.1°; P = .001) and longer grafts (46 vs 41 mm; P = .03) compared with allograft patients. A total of 13 (23.6%) patients required revision surgery in the allograft group compared with 11 (7.3%) in the autograft group (P < .001). After controlling for sex, procedure (reconstruction vs augmentation), and previous surgery, the odds of revision were higher for allograft patients (OR, 4.1; 95% CI, 1.5-11.6). No significant differences in conversion to THA were observed between groups (allograft = 9%; autograft = 6%; P = .50), even after adjustment for the above covariates (OR, 2.3; 95% CI, 0.6-7.9). No differences in postoperative patient-reported outcome measures or patient satisfaction were observed between groups.

CONCLUSION

Labral augmentation or reconstruction with autograft has a significantly lower revision rate than labral augmentation or reconstruction with allograft.

Complete Capsular Closure Provides Higher Rates of Clinically Significant Outcome Improvement and Higher Survivorship Versus Partial Closure After Hip Arthroscopy at Minimum 5-Year Follow-Up

PURPOSE

To (1) compare the rates of reaching threshold hip-specific outcome scores for achieving the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) in patients who underwent partial versus complete T-capsulotomy repair and (2) identify the failure rates in each group 5 years after undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from consecutive patients who underwent hip arthroscopy for FAIS performed by a single fellowship-trained surgeon from January 2011 to March 2013 were collected and analyzed. Baseline data, hip-specific outcomes, and clinical failure rates were recorded at a minimum of 5 years postoperatively. Patients with partial T-capsulotomy repair were matched 1:3 by age, body mass index, and sex to patients with complete T-capsulotomy repair. Threshold scores for achieving the MCID and PASS were calculated and compared between the 2 groups. Additionally, rates of revision and conversion to total hip arthroplasty (THA) were compared between the groups.

RESULTS

A total of 379 patients were available for analysis (39 partial and 340 complete repairs), with 100 patients included in the matching process (25 in the partial-repair group and 75 in the complete-repair group). Comparison of radiographic parameters, including the Tönnis grade, alpha angle, and lateral center-edge angle, between the 2 groups showed no statistically significant difference (P > .05 for all). Comparison of postoperative score averages between the partial- and complete-closure groups showed a significant difference in the Hip Outcome Score-Activities of Daily Living Subscale (85.4 ± 17.7 vs 94.6 ± 7.8, P < .001), Hip Outcome Score-Sports Subscale (76.6 ± 26.2 vs 89.3 ± 16.8, P = .034), modified Harris Hip Score (83.2 ± 19.7 vs 90.5 ± 11.2, P = .035), and visual analog scale pain score (24.5 ± 30.8 vs 13.4 ± 15.8, P = .035). A total of 65 complete-repair patients (95.6%) achieved the MCID for at least 1 outcome measure versus 18 patients with partial repair (78.3%) (P = .04). A total of 69 complete-repair patients (92%) achieved the PASS for at least 1 outcome measure versus 18 partial-repair patients (72%) (P = .017). Of the 39 partial-repair patients, 35.9% (n = 14) underwent revision or conversion to THA, as compared with 2.9% (n = 10) in the overall cohort.

CONCLUSIONS

At a minimum 5-year follow-up, patients with complete capsular closure after hip arthroscopy for FAIS show superior long-term outcomes and achieve higher rates of meaningful clinical success when compared with patients with partial capsular closure. Furthermore, patients with partial capsular repair undergo revision or conversion to THA at high rates.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Decreased Hip Labral Width Measured via Preoperative Magnetic Resonance Imaging Is Associated With Inferior Outcomes for Arthroscopic Labral Repair for Femoroacetabular Impingement

PURPOSE

To determine the association between labral width as measured on preoperative magnetic resonance imaging (MRI) and hip-specific validated patient self-reported outcomes at a minimum of 2 years' follow-up.

METHODS

We performed an institutional review board-approved retrospective review of prospectively gathered hip arthroscopy patients from 2010 to 2017. The inclusion criteria were defined as patients aged 18 to 65 years with radiographic evidence of femoroacetabular impingement who underwent a primary labral repair and had a minimum of 2 years' clinical follow-up. The exclusion criteria were defined as inadequate preoperative imaging, prior hip surgery, Tönnis grade 1 or higher, or lateral center-edge angle lower than 25°. An a priori power analysis was performed. MRI measurements of labral width were conducted by 2 blinded, musculoskeletal fellowship-trained radiologists at standardized "clock-face" locations using a previously validated technique. Outcomes were assessed using the Harris Hip Score (HHS), modified Harris Hip Score (mHHS), and Non-arthritic Hip Score (NAHS). For the mHHS, scores of 8 and 74 were used to define the minimal clinically important difference and patient acceptable symptomatic state, respectively. Patients were divided into groups by a labral width less than 1 SD below the mean (hypoplastic) or widths above 1 SD below the mean. Statistical analysis was performed using linear and polynomial regression; the Mann-Whitney U, χ², and Fisher exact tests; and intraclass correlation coefficient testing.

RESULTS

A total of 103 patients (107 hips) met the inclusion criteria (mean age, 39.4 ± 17 years; body mass index, 25.0 ± 4; 51% right sided; 68% female patients; mean follow-up, 76.5 ± 19.1 months [range, 30.0-113.0 months]). Mean labral width at the 11:30 clock-face position (indirect rectus), 3-o'clock position (psoas U), and 1:30 clock-face position (point halfway between the 2 aforementioned positions) was 7.1 ± 2.2 mm, 7.0 ± 2.0 mm, and 5.5 ± 1.9 mm, respectively. Intraclass correlation coefficient agreements were good to excellent between readers at all positions (0.83-0.91, P < .001). The preoperative HHS, mHHS, and NAHS were not statistically significantly different (P > .05) between the 2 groups. Sex, laterality, and body mass index were not predictive of outcomes (P > .05). The postoperative HHS, mHHS, and NAHS were found to be significantly lower in the hypoplastic group at each location tested (P < .01), including the mHHS at the 11:30 clock-face position (69 vs 87), 3-o'clock position (70 vs 87), and 1:30 clock-face position (71 vs 87). The proportion of patients with hypoplastic labra who reached the minimal clinically important difference was significantly lower (P < .001) at the 11:30 clock-face position (50% vs 91%), 3-o'clock position (56% vs 90%), and 1:30 clock-face position (58% vs 91%) in comparison to the non-hypoplastic labrum group. The proportion of patients with hypoplastic labra above the patient acceptable symptomatic state was significantly lower (P < .001) at the 11:30 clock-face position (44% vs 83%), 3-o'clock position (37.5% vs 84%), and 1:30 clock-face position (42% vs 85%) in comparison to the non-hypoplastic labrum group. Linear regression modeling was not significant at any position (P > .05). Polynomial regression was significant at the 11:30 clock-face position (R² = 0.23, P < .001), 3-o'clock position (R² = 0.17, P < .001), and 1:30 clock-face position (R² = 0.26, P < .004).

CONCLUSIONS

Hip labral width less than 1 SD below the mean measured via preoperative MRI was associated with significantly worse functional outcomes after arthroscopic labral repair and treatment of femoroacetabular impingement. The negative relation between labral width and outcomes may be nonlinear.

LEVEL OF EVIDENCE

Level IV, case series with subgroup analysis.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R ² = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

The impact of mental health disorders on outcomes following hip arthroscopy for femoroacetabular impingement syndrome: a systematic review

Hip arthroscopy for femoroacetabular impingement syndrome (FAI) has been shown to be beneficial in the short- to medium-term though outcomes vary between individuals. Multiple factors have been suggested to affect outcomes including pre-operative mental health disorders. We undertook a systematic review to assess the evidence relating to the effect of pre-existing mental health disorders on the outcomes following hip arthroscopy for FAI. Following PRISMA guidelines, a multi-database search was undertaken using three key concepts: 'mental health', 'FAI' and 'hip arthroscopy'. Results were screened and data extracted from relevant studies. A total of six studies met the inclusion criteria including 2248 hips, all published between 2017 and 2019. All studies were of evidence level III or IV with reasonable methodological quality. One study demonstrated pre-operative depression to be related to altered pain reduction in the short-term following surgery. Three studies reported inferior outcomes in the medium-term (1-2 years) in those with worse mental health. One study demonstrated an increased risk of persistent pain 2 years following surgery and one a reduced chance of returning to active military service following surgery in those with worse mental health. Despite inferior outcomes individuals with mental health disorders did still benefit from surgery in general. In conclusion, the presence of pre-existing poor mental health is associated with inferior outcomes in the medium-term following arthroscopic surgery for FAI. Surgeons should consider screening patients for mental health disorders before surgery and counselling them appropriately as to the potential for less satisfactory surgical outcomes.

Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement Syndrome in NCAA Division I Athletes: Experience at a Single Institution

Background:

The rate of return to sport after surgical treatment of femoroacetabular impingement (FAI) syndrome (FAIS) has been studied in high-level athletes. However, few studies examining this rate have focused exclusively on National Collegiate Athletic Association (NCAA) Division I athletes.

Purpose:

To evaluate the return-to-sport rate after hip arthroscopy for FAIS and to examine the influence of sport type on the clinical presentation of FAIS in collegiate athletes.

Study Design:

Case series; Level of evidence, 4.

Methods:

Included in this study were NCAA Division I student-athletes who underwent hip arthroscopy for FAIS at our institution between 2010 and 2017. Exclusion criteria were history of previous hip pathology, pediatric hip disease, radiographic evidence of osteoarthritis (Tönnis grade >0), prior lower extremity procedure, history of chronic pain, osteoporosis, or history of systemic inflammatory disease. Athletes were categorized into 6 subgroups based on the type of sport (cutting, contact, endurance, impingement, asymmetric/overhead, and flexibility) by using a previously reported classification system. Patient characteristics and preoperative, intraoperative, and return-to-sport variables were compared among sport types.

Results:

A total of 49 hip arthroscopies for FAIS were performed in 39 collegiate athletes (10 females, 29 males; mean age, 19.5 ± 1.3 years). A total of 1 (2.6%) cutting athlete, 15 (38.5%) contact athletes, 8 (20.5%) impingement athletes, 6 (15.4%) asymmetric/overhead athletes, and 9 (23.1%) endurance athletes were included in the study. There were no differences among sports groups with respect to the FAI type. Endurance athletes had lower rates of femoral osteochondroplasty (45.5%) and labral debridement (0.0%) (P < .0001). Contact sport athletes had higher rates of labral debridement (50.0%; P < .0001). Patients were evaluated for return to sport at an average of 1.96 ± 0.94 years. Overall, the return-to-sport rate was 89.7%. There were no differences in return-to-sport rates based on the sport type except for endurance athletes, who returned at a lower rate (66.6%; P < .001). No differences in return-to-sport rate (P = .411), duration after return (P = .265), or highest attempted level of sport resumed (P = .625) were found between patients who underwent labral repair versus debridement.

Conclusion:

Collegiate-level athletes who underwent hip arthroscopy for FAIS returned to sport at high and predictable rates, with endurance athletes possibly returning to sport at lower rates than all other sport types. Surgical procedures may be influenced by sport type, but the rate of return to sport between athletes who underwent labral debridement versus labral repair was similar.

Findings on repaired full-thickness acetabular articular cartilage defects during revision hip arthroscopy allowing a second look

Full-thickness acetabular articular cartilage defects (FAACD) are found on most hips with femoroacetabular impingement (FAI) with a wave sign in the acetabulum. When not repaired it can produce pain and catching sensation. Multiple arthroscopic techniques for repairing this chondral lesion exist, but only few show the quality of the repair on a second look. The purpose of this study is to evaluate the quality of the repaired cartilage during revision hip arthroscopy (RHA) allowing a second look in patients treated of FAACD. A total of 13 hips with FAACD repaired in the past underwent RHA for ongoing pain. Signs of persistent chondral defects or the ability to elevate the articular cartilage from subchondral bone were evaluated by zones. Those with persistent defects were re-repaired. All patients had FAACD lesions in zones I, II and III diagnosed in the index hip arthroscopy. The most common finding at the RHA was the presence of bone growth or residual impingement. Before FAACD repair, 11 (85%) hips had the wave sign, while 2 (15%) hips had it in RHA. Five (38%) hips had residual delamination in the second look, these patients had residual FAI, were ≥58 years or waited >6 months to be revised. The wave sign was not observed in 85% of the revised hips, indicating the technique was successful in most cases and was not the principal cause of their ongoing pain. This technique achieved the stated goal of stabilizing the articular cartilage seen in the wave sign.

Two-Year Patient-Reported Outcomes for Patients Undergoing Revision Hip Arthroscopy with Capsular Incompetency

PURPOSE

To determine clinical outcomes of patients undergoing revision hip arthroscopy for failure to improve with magnetic resonance imaging (MRI) and intraoperative evidence of a capsular incompetency as compared with (1) patients undergoing revision hip arthroscopy without evidence of a capsular incompetency and (2) patients undergoing primary surgery for femoroacetabular impingement syndrome (FAIS) at a minimum follow up of 2 years.

METHODS

Data from consecutive patients undergoing revision hip arthroscopy with MRI/arthrogram-confirmed capsular incompetency between January 2012 and June 2016 were analyzed. All revision patients with capsular incompetency was matched 1:1 by age and body mass index to FAIS revision patients without capsular incompetency and primary FAIS patients. Outcomes included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Subscale (SS), Modified Harris Hip Score (mHHS), pain, and satisfaction. The minimal clinically important difference was calculated for HOS-ADL, HOS-SS, and mHHS.

RESULTS

In total, 49 patients (54.4%) of 90 undergoing revision hip arthroscopy had MRI evidence of a capsular incompetency. Most patients were female (79.6%), with a mean age of 30 ± 10.5 years and body mass index of 25.7 ± 5.5. The difference among pre- and postoperative HOS-ADL, HOS-SS, mHHS, and visual analog scale score for pain were all statistically significant (P < .05). Analysis of reported outcomes among matched groups demonstrated statistically significant differences, with the group undergoing primary surgery having the greatest 2-year outcomes. Only 66.7% of patients undergoing revision surgery with capsular incompetency achieved a minimal clinically important difference; however, there was no significant difference when compared with revision patients without capsular incompetency. When compared with patients undergoing primary surgery, the difference in frequency was statistically significant (66.7% vs 91.3%; P < .001).

CONCLUSIONS

More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. Revision arthroscopy for capsular incompetency results in significantly improved 2-year outcomes. However, patients undergoing revision for capsular incompetency and intact capsule revision patients reported significantly lower outcomes compared with primary patients.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Heterotopic ossification: radiological and pathological review

Background Heterotopic Ossification (HO) is a common condition referring to ectopic bone formation in soft tissues. It has two major etiologies, acquired (more common) and genetic. The acquired form is closely related to tissue trauma. The exact pathogenesis of this disease remains unclear; however, there is ongoing research in prophylactic and therapeutic treatments that is promising. Conclusions Due to HO potential to cause disability, it is so important to differentiate it from other causes in order to establish the best possible management.

Contemporary Management of the Hip Capsule During Arthroscopic Hip Preservation Surgery

PURPOSE OF REVIEW

The importance of the hip capsule and its effect on hip biomechanics, functional outcomes, and hip arthroscopy success rates has been demonstrated in recent studies. These results have led to a shift in management of the hip capsule, where an increasing number of surgeons routinely perform complete capsular closure. The purpose of this review is to highlight recent studies evaluating the hip capsule and describe contemporary capsular management and repair.

RECENT FINDINGS

Biomechanical studies using cadaveric models have demonstrated that complete capsular closure restores hip distraction, rotation, and extension forces back to the native, intact state. Additionally, capsular closure by plication results in quantifiable intraarticular volume reduction, which increases hip stability, particularly in cases of patulous capsule and hypermobility. Clinical studies have demonstrated superior patient-reported functional outcomes and decreased failure rates when undergoing hip arthroscopy with comprehensive capsular management for femoroacetabular impingement surgery. Complete capsular management, including appropriate capsulotomy and subsequent closure, is critical for restoring biomechanical properties of the hip, ensuring high survivorship and improving functional outcomes. This review provides an update on the effects of contemporary capsular management as well as a detailed description of efficient T-capsulotomy and comprehensive capsule closure via plication.

Preserving the chondrolabral junction reduces the rate of capsular adhesions

The operative treatment of pincer-type femoroacetabular impingement (FAI) has become an increasingly more common procedure. Classically, the labrum is incised at the chondrolabral junction (CLJ), or a concurrent tear is extended to allow access to the acetabular rim facilitating acetabuloplasty. The labrum is subsequently repaired using suture anchors. More recently, acetabuloplasty has been performed without incising the labrum and negating the need to use suture anchors. The aim of this study is to determine whether preserving the CLJ reduces the incidence of revision hip arthroscopy for the treatment of capsulolabral adhesions. This retrospective study compared two cohorts of patients undergoing hip arthroscopy for pincer-type FAI from August 2002 to April 2015. The groups analysed were patients undergoing acetabuloplasty with labral repair (LR) and those with no labral repair (NLR). The revision rates and causes for revision were compared using the χ² analysis. There were 1010 cases in total. Acetabuloplasty with LR was performed in 546 hips (519 patients), while acetabuloplasty with NLR was performed in 464 hips (431 patients). In the LR group, there were 54 (9.9%) revisions, 25 (46%) of which were due to capsulolabral adhesions. The NLR group had 36 (7.8%) revisions with six (17%) due to capsulolabral adhesions. Preserving the CLJ, thereby avoiding the need for drilling and the insertion of suture anchors, when performing an acetabuloplasty for pincer-type FAI, significantly reduces the rate of symptomatic adhesions requiring revision arthroscopy.

The Influence of Pain in Other Major Joints and the Spine on 2-Year Outcomes After Hip Arthroscopy

PURPOSE

To determine whether patients who have pain in other major joints or the spine have poorer postsurgical outcomes than patients without comorbid orthopaedic pain.

METHODS

We performed a review of a prospectively maintained institutional surgical registry of patients who underwent hip arthroscopy between January 1, 2012, and July 16, 2015, by a single surgeon, with a minimum of 2 years of postoperative follow-up. A musculoskeletal morbidity (MSM) score was assigned to each patient preoperatively based on the presence of pain in other joints and the spine (grade 1, hip only; grade 2, hip and other major joints without spine; grade 3, hip with spine; and grade 4, hip and other major joints with spine). Preoperatively and at 2 years postoperatively, functional outcomes were measured using the Hip Outcome Score-Activities of Daily Living (HOS-ADL), and the percentages of patients achieving a minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS) were calculated.

RESULTS

In total, 821 patients were identified, of whom 700 (85.3%) completed 2-year follow-up. Preoperatively, MSM grade 1 patients had a higher HOS-ADL than grade 2 patients (P = .02), but there was no difference between grade 1 and grade 3 patients (P = .63) or between grade 1 and grade 4 patients (P = .14). Likewise, there was no difference in the preoperative HOS-ADL among grades 2, 3, and 4. Patients with MSM grades 1 and 2 were younger than those with grades 3 and 4. At 2 years postoperatively, MSM grade 1 patients had higher HOS-ADL values than grade 3 (P = .01) and grade 4 (P = .02) but not grade 2 (P = .07) patients. Overall, 84% of patients showed an MCID and 72% of patients achieved a PASS with regard to the HOS-ADL. There were no statistically significant differences among MSM grades in terms of the MCID or PASS.

CONCLUSIONS

Overall, 84% of patients improved with hip arthroscopy by MCID criteria for the HOS-ADL. Patients with no pain in other joints (MSM grade 1) had better 2-year postoperative HOS-ADL values after hip arthroscopy than patients with spine pain (grades 3 and 4). However, there were no significant differences in the MCID or PASS among patients with regard to MSM grade. A total of 40.5% of patients who underwent hip arthroscopy had pain in another joint. A limitation, however, is that there is potential for a type II error, in that there may not have been a sufficient number of patients studied to detect a significant difference in outcome among patients with different grades of musculoskeletal comorbidity.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

A Systematic Summary of Systematic Reviews on the Topic of Hip Arthroscopic Surgery

BACKGROUND

There is a rapidly growing body of literature on the topic of hip arthroscopic surgery.

PURPOSE

To provide an overall summary of systematic reviews published on the indications, complications, techniques, outcomes, and information related to hip arthroscopic surgery.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

A systematic review of all hip arthroscopic surgery-related systematic reviews published between January 2000 and May 2018 was performed using PubMed, MEDLINE, and the Cochrane Library. Narrative reviews and non-English articles were excluded.

RESULTS

A total of 837 articles were found, of which 85 met the inclusion criteria. Included articles were summarized and divided into 6 major categories based on the subject of the review: femoroacetabular impingement (FAI), non-FAI indications, surgical technique, outcomes, complications, and miscellaneous.

CONCLUSION

A summary of systematic reviews on hip arthroscopic surgery can provide surgeons with a single source for the most current synopsis of the available literature. As the prevalence of orthopaedic surgeons performing hip arthroscopic surgery increases, updated evidence-based guidelines must likewise be advanced and understood to ensure optimal patient management.