A history of spine surgery predicts a poor outcome after hip arthroscopy

Concomitant Ipsilateral Knee Pain Is Associated With Worse Preoperative Functional Status and Short-Term Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome

PURPOSE

(1) To determine the effect of concomitant ipsilateral knee pain (IKP) on short-term outcomes after hip arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) and (2) to determine whether IKP would improve with surgery.

METHODS

Data between September 2021 and May 2022 were reviewed. Patients with a diagnosis of FAIS who underwent hip arthroscopy with a minimum of 1-year follow-up were included. The exclusion criteria were prior ipsilateral hip or knee surgery, hip Tönnis grade greater than 1, knee Kellgren-Lawrence grade greater than 2, hip conditions (avascular necrosis, Legg-Calvé-Perthes disease, pigmented villonodular synovitis, osteoid osteoma, synovial chondromatosis, and developmental dysplasia of the hip), and spine diseases. All patients underwent knee magnetic resonance imaging preoperatively. Preoperative and short-term (1-year) patient-reported outcomes were collected, consisting of the Hip Sports Activity Scale score, weekly sports participation, modified Harris Hip Score (mHHS), 12-component International Hip Outcome Tool (iHOT-12) score, and visual analog pain scale (VAS) scores for the hip and the ipsilateral knee. The percentages of patients achieving the minimal clinically important difference and patient acceptable symptom state (PASS) for the mHHS and iHOT-12 score were calculated. Multivariate regression analysis was performed to determine the effect of IKP severity on postoperative outcomes. Subgroup analysis was performed between patients with IKP alleviation and those without IKP alleviation.

RESULTS

Among the 107 patients included, 47 presented with preoperative IKP. Compared with patients without IKP, the IKP cohort had comparable knee structural abnormalities (all with P > .05). Still, the IKP cohort showed inferior preoperative values for the mHHS (P = .003), iHOT-12 score (P = .016), hip VAS score (P = .001), and weekly sports participation (P = .039). Postoperatively, the IKP cohort had a lower mHHS (P = .046), lower iHOT-12 score (P = .037), and lower hip VAS score (P = .003) and were less likely to achieve the PASS for the mHHS (P = .021) and iHOT-12 score (P = .049). Patients with higher knee VAS scores were less likely to achieve the PASS for the mHHS (odds ratio, 0.61; P = .023). Within the IKP group, the knee VAS score improved from 2.3 to 1.0 (P < .001). Patients with alleviated IKP showed superior postoperative iHOT-12 scores (P = .038) compared with patients with persistent IKP.

CONCLUSIONS

Concomitant IKP at baseline negatively affected preoperative status and short-term clinical outcomes after arthroscopic treatment of FAIS. Patients with IKP were less likely to meet clinical thresholds. Most patients achieved IKP alleviation postoperatively, which was associated with superior clinical outcomes.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

Over 50% of Studies Report Low-Back Pain Is Associated With Worse Outcomes After Hip Arthroscopy When Compared With a Control Group: A Systematic Review

PURPOSE

To review outcomes of patients with low-back pathology undergoing primary hip arthroscopy for the treatment of femoroacetabular impingement (FAI) syndrome.

METHODS

The PubMed, Cochrane Trials, and Scopus databases were queried in June 2022 to conduct this systematic review using the following terms: ("hip" OR "femoroacetabular impingement") AND ("arthroscopy" OR "arthroscopic") AND ("spine" OR "lumbar" OR "sacral" OR "hip-spine" OR "back") AND ("outcomes"). Articles were included if they reported on patient-reported outcomes (PROs) and/or clinical benefit of patients undergoing hip arthroscopy with concomitant low-back pathology. The review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) criteria. Case reports, opinion articles, review articles, and technique articles were excluded from this study. Forest plots were created to analyze preoperative and postoperative outcomes among patients with low-back pathology.

RESULTS

Fourteen studies were included in the review. There were 750 hips with low-back pathology and FAI (hip-spine syndrome) and 1,800 hips with only FAI (no hip-spine syndrome). All 14 studies reported PROs. In 4 studies in the group with hip-spine syndrome and 8 studies in the group with FAI without low-back pathology, the respective cohorts were reported to achieve the minimal clinically important difference in at least 1 PRO at a rate of 80%. Eight studies reported that patients with low-back pathology were associated with inferior outcomes or clinical benefit compared with patients without low-back pathology.

CONCLUSIONS

Patients undergoing primary hip arthroscopy with concomitant low-back pathology can expect favorable outcomes, but outcomes are superior in patients undergoing hip arthroscopy for FAI alone compared with FAI with concomitant low-back pathology.

LEVEL OF EVIDENCE

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

Outcomes of Hip Arthroscopy in the Setting of Concomitant Symptomatic Lumbosacral Spine Pathology: A Matched Control Study With Minimum 24-Month Follow-up

BACKGROUND

The overlapping biomechanical relationship between the lumbosacral spine and pelvis poses unique challenges to patients with concomitant pathologies limiting spinopelvic range of motion.

PURPOSE

To assess the influence of concomitant, symptomatic lumbosacral spine pathology on patient-reported outcome measures (PROMs) after hip arthroscopy for the treatment of femoroacetabular impingement (FAI) and symptomatic labral tears.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective query of prospectively collected data identified patients aged ≥18 years with a minimum 24-month follow-up who underwent hip arthroscopy by a single surgeon for the treatment of symptomatic labral tears secondary to FAI. Patients were stratified into cohorts based on the presence (hip-spine [HS]) or absence (matched control [MC]) of symptomatic lumbosacral spine pathology. Inclusion within the HS cohort required confirmation of lower back pain/symptoms on preoperative surveys plus a diagnosis of lumbosacral spine pathology verified by radiology reports and correlating clinical documentation. Patients with previous spine surgery were excluded. PROMs were compared between groups, along with rates of achieving minimal clinically important difference (MCID) thresholds, Patient Acceptable Symptom State (PASS) thresholds, revision arthroscopy, and conversion to total hip arthroplasty (THA).

RESULTS

A total of 70 patients with lumbosacral pathology were coarsened exact matched to 87 control patients without spinal pathology. The HS cohort had preoperative baseline scores that were significantly worse for nearly all PROMs. Follow-ups at 3, 6, 12, and 24 months displayed similar trends, with the HS cohort demonstrating significantly worse scores for most collected outcomes. However, at every time point, HS and MC patients exhibited similar magnitudes of improvement across all PROM and pain metrics. Furthermore, while significantly fewer HS patients achieved PASS for nearly all PROMs at 12- and 24-month follow-ups, MCID thresholds were reached at similar or greater rates across all PROMs relative to the MC cohort. Finally, there were no significant differences in rates of revision or THA between cohorts at maximum available follow-up.

CONCLUSION

After hip arthroscopy to address labral tears in the setting of FAI, patients with symptomatic lumbosacral pathologies and no history of spine surgery were found to exhibit inferior pre- and postoperative PROMs but achieved statistically similar clinical benefit and rates of PROM improvement through 24-month follow-up compared with the MC cohort with isolated hip disease. These findings aid in providing a realistic recovery timeline and evidence that coexisting hip and spine disorders are not a contraindication for arthroscopic hip preservation surgery.

Editorial Commentary: Restrictions in Spinal Motion Result in Lower Outcome Scores After Hip Arthroscopy

The critical consideration in determining the efficacy of hip surgery is patient-reported outcomes, specifically the achievement of the clinical threshold. Several studies examined the achievement of the clinical threshold following hip arthroscopy (HA) in the presence of coexisting lumbar spine disease. The condition related to the spine receiving a lot of focus in recent research is the lumbosacral transitional vertebrae (LSTV). However, this condition could be just the tip of the iceberg. To forecast the outcomes of HA, it is far more important to comprehend spinopelvic motion. Since higher-grade LSTV is associated with less lumbar spine flexibility and reduces the ability to antevert acetabulum, it is possible that LSTV severity or grading could be one of the indicators of less effective operation "especially in "hip users"' (hip users are defined as patents who are more dependent on on hip motion than spinal motion). In light of this, lower-grade LSTV ought to have a less significant impact on surgical outcomes than higher-grade LSTV.

The Outcome of Hip Arthroscopy in the Setting of Lumbar Spine Disease Is Beneficial, Yet Limited: A Systematic Review of Existing Evidence

PURPOSE

To compare hip arthroscopy outcomes in femoroacetabular impingement (FAI) patients with concurrent symptomatic lumbar spine disease to the outcomes of arthroscopic FAI patients without spine disease.

METHODS

A systematic review was performed according to PRISMA guidelines via PubMed, Cochrane, Embase, and Google Scholar databases. Studies were valid for inclusion if they had an average follow-up ≥12 months and compared patient-reported outcome measures (PROMs) in hip arthroscopy patients with and without concurrent spinal disease. Data collected included study characteristics, patient demographics, follow-up intervals, surgical indications, spinal pathology, PROMs, and reoperation rates.

RESULTS

Twelve studies were included in this systematic review. 3,107 patients who underwent hip arthroscopy were evaluated: 1,056 with coexisting lumbar spine disease (spine cohort) and 2,051 control subjects without spine disease (control cohort). The average follow-up period was 24 months. Across included studies, there were 35 instances wherein postoperative PROM scores reported by each cohort were compared. In all 35 instances, the spine cohort reported inferior postoperative PROM scores with the difference being significant (P < .05) on 23 PROMs. Collectively, 23 cases were available contrasting the proportion of each cohort to achieve the minimal clinically important difference (MCID). In 22 (95.65%) of these cases, the spine cohort achieved the MCID at a lower rate than the control cohort. There were 14 PROMs, wherein intragroup analyses were reported that compared the preoperative and postoperative score reported by the spine cohort. On all 14 PROMs, the spine cohort reported significant (P < .05) improvement after arthroscopic intervention.

CONCLUSION

FAI patients with coexisting lumbar spine pathology experience significant improvement from baseline state after arthroscopic intervention. However, the postoperative outcomes reported are inferior, and the improvement from arthroscopy was limited when compared to surgical control subjects with FAI and normal spinal anatomy.

LEVEL OF EVIDENCE

Level IV: systematic review of Level II, III, and IV studies.

Relationship between Spinopelvic Parameters and Hip Function in Patients with Femoroacetabular Impingement at Diagnosis: A Cross-Sectional Study

Purpose

The aim of this study was to determine correlation between the spinopelvic parameters in sitting and standing positions (sacral slope [SS], lumbar lordosis [LL], spinopelvic tilt [SPT], pelvic incidence [PI], and pelvic femoral angle [PFA]), with hip function assessed using the modified Harris hip scores (mHHs) in patients with symptomatic femoroacetabular impingement (FAI) at diagnosis.

Materials and Methods

A retrospective study of 52 patients diagnosed with symptomatic FAI was conducted. Evaluation of the spinopelvic complex in terms of SS, LL, SPT, PI and PFA was performed using lateral radiographs of the pelvis and lumbosacral spine in standing and sitting positions. Assessment of hip function at diagnosis was performed using the mHHs. Calculation of spinopelvic mobility was based on the difference (Δ) between measurements performed in standing and sitting position.

Results

The median time of pain evolution was 11 months (interquartile range [IQR], 5-24 months) with a median mHHs of 66.0 points (IQR, 46.0-73.0) at diagnosis. The mean change of LL, SS, SPT, and PFA was 20.9±11.2°, 14.2±8.6°, 15.5±9.0°, and 70.7±9.5°, respectively. No statistically significant correlation was observed between spinopelvic parameters and the mHHs (P>0.05).

Conclusion

Radiological parameters of the spinopelvic complex did not show correlation with hip function at the time of diagnosis in patients with symptomatic FAI. Conduct of further studies will be required in the effort to understand the effect of the spinopelvic complex and its compensatory mechanics, primarily between the hip and spine, in patients with FAI before and after hip arthroscopy.

Determining anterior hip coverage in patients with hip dysplasia using the anterior center-edge angle on Lequesne's false-profile radiograph and on computed tomography

Anterior hip coverage is important for hip stability. As a parameter of anterior hip coverage, the anterior center-edge angle on false-profile radiograph (ACEA FP) is associated with clinical outcomes. With the widespread application of computed tomography (CT), the anterior center-edge angle on CT (ACEA CT) has also been used to measure anterior hip coverage. Little is known about the reproducibility of the ACEA FP and ACEA CT in patients with hip dysplasia or the correlation between the ACEA CT and ACEA FP. In total, 49 hips of 49 patients who underwent periacetabular osteotomy in our center were included. The lateral center-edge angle, Tönnis angle, ACEA FP and ACEA CT were determined. We assessed the intraobserver and interobserver reliability of the ACEA FP and ACEA CT, the effect of the Tönnis angle on the reliability of the ACEA FP and ACEA CT and the correlation between the ACEA CT and ACEA FP. The intraobserver and interobserver interclass correlation coefficients of the ACEA FP were good, and those of the ACEA CT were very good. The Tönnis angle was weakly correlated with inconsistent ACEA FP measurements (P = 0.008) but not with inconsistent ACEA CT measurements (P = 0.600). No correlation between ACEA FP and ACEA CT measurements was observed (P = 0.213-0.665). The reproducibility of the ACEA CT is more consistent than that of the ACEA FP. The oblique acetabular roof had an effect on determining the ACEA FP but not on determining the ACEA CT. No correlation was observed between the measured ACEA FP and ACEA CT values, so the clinical evidence obtained from the ACEA FP cannot be directly applied to the ACEA CT.

Hip-Spine Syndrome in the Nonarthritic Patient

Hip-spine syndrome refers to concurrent hip and spine pathology with overlapping symptoms. Most of the literature has studied it in relation to total hip arthroplasty literature and has been shown to increase dislocation risk. Lumbar spine and pelvic mobility have been studied less frequently in relation to nonarthritic pathologic hip states. Understanding the biomechanical relationship between the lumbar spine, pelvis, and hip can help elucidate how hip-spine syndrome affects the nonarthritic hip and how it impacts outcomes of hip arthroscopy. Changes in lumbar spine motion may be the reason certain predisposed patients develop symptomatic femoroacetabular impingement (FAI) or ischiofemoral impingement. Some athletes may be "hip users" with a low pelvic incidence, making them more reliant on hip motion due to less-intrinsic lumbopelvic motion. When these patients have FAI morphology, their increased reliance on hip motion makes them prone to experiencing femoroacetabular contact and concurrent symptoms. Other athletes may be "spine users," with larger pelvic incidence and more baseline lumbopelvic motion, making them less reliant on hip motion and therefore less prone to experiencing hip impingement even with hip FAI morphology. Hip-spine syndrome also appears to have an impact on patient selection, role of nonoperative treatment, and hip arthroscopy surgical outcomes. Identifying patients with concurrent pathology may allow surgeons to recommend targeted physical therapy or counsel patients better on their expectations after surgery.

Hip Spine Syndrome Negatively Impacts Arthroscopic Outcomes in the Management of Femoroacetabular Impingement Syndrome: A Systematic Review

To determine whether the presence of spine pathology affects clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) in the setting of hip-spine syndrome (HSS) METHODS: A systematic review of PubMed and Cochrane was conducted. Primary research articles evaluating patient-reported outcomes (PRO) after hip arthroscopy for FAIS in the presence of concomitant spine pathology were considered RESULTS: Literature review identified 12 studies meeting criteria. In 2109 FAIS patients undergoing hip arthroscopy, 591 had concomitant spine pathology. Baseline PROs in the hip-spine (modified Harris Hip Score [mHHS]: 39.8-65.29 vs 56.9-78.8, 8 studies; non-arthritic hip score [NAHS]: 42.2-51.5 vs 68.2-75.2, 4 studies; hip outcome score-activities of daily living [HOS-ADL]: 45.9-71.1 vs 49.3-89.51, 9 studies; hip outcome score-Sport (HOS-Sport): 22.8-49.6 vs 50.6-73.1, 3 studies; international hip outcome tool-33 [iHOT-12]: 38.0 vs 66.0, 1 study; visual analog scale [VAS] Pain: 6.43-6.56 vs 1.18-3.60, 3 studies; VAS Satisfaction: 7.18-7.46 range at follow-up, 2 studies) and control (mHHS: 39.3-64.9 vs 70.2-92.6, 6 studies; NAHS: 42.8-54.2 vs 74.0-87.1, 4 studies; HOS-ADL: 59.0-76.4 vs 75.4-97.1, 4 studies; HOS-Sport: 38.1-55.1 vs 60.9-93.9, 3 studies; iHOT-12: 43.4 vs 89.8, 1 study; VAS Pain: 6.18-6.22 vs 1.82-3.44, 2 studies; VAS Satisfaction: 7.74-8.22 range at follow up, 2 studies). Minimal clinically important difference threshold rates achieved in the hip-spine (44.1-86.7, 4 studies) cohorts were significantly lower than control (79.4-88.2%; 4 studies) cohorts in 3 studies. Patient-acceptable symptomatic state threshold rates achieved in the hip-spine (42-63.5, 3 studies) cohorts were significantly lower than control (58.8-81.0, 3 studies) in 1 study. There was no statistical difference in complication and reoperation rates between cohorts CONCLUSION: FAIS patients with concomitant HSS have improved but inferior outcomes after hip arthroscopy compared to patients without HSS LEVEL OF EVIDENCE: IV, systematic review.

Improvements in lower-extremity patient-reported outcomes after lumbar interbody fusion

OBJECTIVE

Recently, new patient-reported outcome measures (PROMs) of the spine were designed to overcome the limitations of previous spinal PROMs and to consider the whole spine as a single kinetic functional unit. Owing to the significance of spine-hip-knee and global body balance, the spine and lower extremities cannot be considered separately. However, no reports have evaluated lower-extremity functional outcome using PROMs after lumbar spine surgery. The authors aimed to elucidate changes in hip and knee PROMs after lumbar interbody fusion and to evaluate the sagittal spinopelvic radiographic parameters that were most strongly correlated with lower-extremity PROMs.

METHODS

In 2018, the authors consecutively evaluated patients who underwent lumbar interbody fusion surgery with at most three levels. Preoperative and 1-year postoperative clinical and radiographic data were assessed. Spinal functional outcomes were measured with the Oswestry Disability Index (ODI), visual analog scale (VAS) for pain, and Scoliosis Research Society-22r (SRS-22r) questionnaire. Lower-extremity functional outcomes were evaluated with the Harris Hip Score (HHS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Linear regression was used to evaluate the relationship between spinal and lower-extremity PROMs and spinopelvic radiographic parameters.

RESULTS

The authors enrolled 67 patients, with a mean age of 66.4 years. The average number of surgical levels was 1.7. All assessed PROMs improved significantly after surgery (p < 0.001 for ODI, p < 0.001 for VAS, p = 0.017 for SRS-22r, p = 0.042 for HHS, and p = 0.033 for WOMAC). Spinopelvic parameters, including lumbar lordosis (LL), pelvic tilt (PT), C7 sagittal vertical axis, and sagittal radiographic parameters of hip and knee, significantly improved after surgery. On linear regression analysis, HHS and WOMAC correlated with LL and PT, respectively (β = 0.554 and p = 0.043 for correlation of HHS with LL; β = 1.573 and p = 0.021 for correlation of WOMAC with PT).

CONCLUSIONS

The current study demonstrated that lumbar fusion surgery may induce postoperative improvements in lower-extremity functional and radiological outcomes. However, among radiographic parameters, changes in LL and PT were the most strongly associated with lower-extremity PROMs.

Limited lumbopelvic mobility does not influence short-term outcomes after primary hip arthroscopy: a propensity-matched controlled study

There is a paucity of literature investigating the effect of lumbopelvic mobility on patient-reported outcome scores (PROs) after primary hip arthroscopy. The purpose of this study was (i) to report minimum 1-year PROs in patients with limited lumbopelvic mobility (LM) who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (ii) to compare clinical results with a propensity-matched control group of patients with normal lumbopelvic mobility (NM). Data were reviewed for surgeries performed between November 2019 and March 2020. Patients were considered eligible if they received a primary hip arthroscopy for FAIS in the setting of LM (seated to standing change in sacral slope ≤ 10°). LM patients were propensity-matched to a control group of patients with normal lumbopelvic motion (seated to standing change in sacral slope > 10°) for comparison. A total of 17 LM and 34 propensity-matched NM patients were included in the study. LM patients showed significant improvement in all outcome measures and achieved the minimum clinically important difference (MCID) and patient acceptable symptomatic state (PASS) at high rates for modified Harris Hip Score (MCID: 94% and PASS: 82%) and International Hip Outcome Tool-12 (iHOT-12; MCID: 94% and iHOT-12: 76%). When LM patients were compared to a propensity-matched control group of NM patients, they demonstrated similar postoperative PROs and rates of achieving MCID/PASS. LM patients who undergo primary hip arthroscopy may expect favorable short-term PROs at minimum 1-year follow-up. These results were comparable to a control group of NM patients.

Concomitant Lumbar Spinal Stenosis Negatively Affects Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

The purpose of this study was to assess the prognostic effect of lumbar spinal stenosis on clinical outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAI).

METHODS

Patients undergoing hip arthroscopy between September 2009 and December 2015 for FAI with concomitant lumbar spinal stenosis (central/neuroforaminal) and a 2-year follow-up were identified (hip-spine). A 1:1 case-matching query using preoperative modified Harris Hip Score (mHHS) within 3 points, body mass index (BMI) within 3 points, age within 5 years, and sex identified a control cohort without spinal pathology. Follow-up patient-reported outcomes (PROs) and clinical failure rates to revision procedure were compared using analysis of variance (ANOVA) and Kaplan-Meier survival analysis.

RESULTS

Twenty-six patients met criteria of the hip-spine group (age: 45.9 ± 12.2 years; BMI: 27.3 ± 5.0 kg/m², baseline mHHS: 44.17 ± 2.76) vs the control group (age: 46.2 ± 12.4 years, P = .94; BMI: 26.7 ± 4.1 kg/m², P = .61; baseline mHHS: 44.27 ± 2.82, P = .98). ANOVA analysis demonstrated that all PROs improved from baseline to 2-year outcomes (P < .001). The hip-spine vs control group had lower 1-year (mHHS: 65.97 ± 5.64 vs 85.04 ± 3.09, P = .006; nonarthritic hip score (NAHS): 70.26 ± 5.71 vs 87.89 ± 2.65, P = .010) and 2-year (mHHS: 69.72 ± 4.92 vs 84.71 ± 2.56, P = .007; NAHS: 72.23 ± 5.18 vs 87.14 ± 2.23, P = .008) outcomes. While there was no difference in patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) rates at 1-year follow-up, the hip-spine group demonstrated lower PASS (42% vs 81%, P = .004) and MCID (58% vs 88%, P = .027) rates at 2 years. Although susceptible to type II error, there was no difference in clinical failure rates to revision procedure (P = .13).

CONCLUSIONS

While net PROs from baseline improve after hip arthroscopy for FAI, the presence of concomitant lumbar spinal stenosis negatively affects postoperative PROs. FAI patients with spinal stenosis should be counseled accordingly.

LEVEL OF EVIDENCE

Level III, case-control study.