Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial

Management of hip osteoarthritis: harnessing the potential of mesenchymal stem cells-a systematic review

INTRODUCTION

Hip osteoarthritis (OA) is a prevalent and debilitating condition, necessitating effective and safe treatment options. This systematic review aims to explore the potential of intra-articular mesenchymal stem cell (MSC) infiltrations as a therapeutic approach for hip OA.

METHODS

Following PRISMA guidelines, a systematic review was conducted, encompassing PubMed, Embase, and Cochrane Library databases. Inclusion criteria involved studies focusing on intra-articular MSC injections in patients with hip OA and reporting pain relief as an outcome measure. Quality assessment utilized the Newcastle-Ottawa scale and methodological index for non-randomized studies.

RESULTS

Ten studies were included in the review, exhibiting varied designs and sample sizes (316 patients). Outcome measures consisted of cartilage repair assessed through MRI and radiographies, pain scores (WOMAC, VAS, NRS), and functional improvements (HOS-ADL, OHS, FRI, PDQQ, LEFS). The studies reported favorable improvements in functional scores, pain relief, and cartilage repair/radiographic findings, with minimal reported adverse events.

CONCLUSIONS

Intra-articular MSC infiltrations demonstrate promise as an effective and safe therapeutic intervention for managing hip OA, offering pain relief and functional enhancements. Nevertheless, limited high-quality studies and outcome measure variations underscore the need for further research to establish definitive treatment guidelines. Future investigations should address optimal MSC utilization, long-term outcomes, and potential complications to ensure the success of MSC-based therapies for hip OA management, ultimately improving patient outcomes. The findings provide valuable insights into the potential of MSC-based treatments for hip OA, advocating further rigorous research in this field.

TRIAL REGISTRATION

The protocol was registered on PROSPERO database (CRD42023436973).

Femoroacetabular impingement syndrome in middle-aged individuals is strongly associated with the development of hip osteoarthritis within 10-year follow-up: a prospective cohort study (CHECK)

OBJECTIVE

The objective is to determine the association and absolute risk of femoroacetabular impingement syndrome (FAIS) for the development of radiographic hip osteoarthritis (RHOA).

METHODS

This is a nationwide, multicentre prospective cohort study (Cohort Hip and Cohort Knee) with 1002 individuals aged between 45 and 65 years. Hips without definitive RHOA (Kellgren-Lawrence (KL) grade≤1) at baseline and with anteroposterior pelvic radiographs at baseline and 10-year follow-up available (n=1386 hips) were included. FAIS was defined by the baseline presence of a painful hip, limited internal hip rotation≤25° and cam morphology defined by an alpha angle>60°. The outcomes were incident RHOA (KL grade≥2 or total hip replacement (THR)) and incident end-stage RHOA (KL≥3 or THR) within 10 years.

RESULTS

Of the 1386 included hips (80% women; mean age 55.7±5.2 years), 21 hips fulfilled criteria for FAIS and 563 hips did not fulfil any of the FAIS criteria (reference group; no symptoms, no signs, no cam morphology). Within 10-year follow-up, 221 hips (38%) developed incident RHOA and 15 hips (3%) developed end-stage RHOA (including 9 hips with THR). Adjusted for sex, age and body mass index, FAIS with cam morphology resulted in an OR of 6.85 (95% CI 2.10 to 22.35) for incident RHOA and 47.82 (95% CI 12.51 to 182.76) for incident end-stage RHOA, compared with hips not having any FAIS criteria. The absolute risk of FAIS was 81% for incident RHOA and 33% for incident end-stage RHOA.

CONCLUSION

FAIS was strongly associated with the development of RHOA within 10 years. Although the baseline prevalence of FAIS was low, the high absolute risk of FAIS for RHOA warrants further studies to determine preventive strategies.

Neuropathic pain is a feature in patients with symptomatic femoral acetabular impingement

Femoral acetabular impingement syndrome (FAIS) is a cause of hip pain thought to be nociceptive, although pain phenotypes e.g., burning, pain attacks, prickling, numbness etc., are reported, mimicking neuropathic pain. Although no lesion to the somatosensory system is identified, neuropathic pain (NeP) may explain why nociceptive-focussed treatments are not always successful.

OBJECTIVE

To identify NeP in patients with FAIS and investigate if related to poorer outcomes.

DESIGN

A secondary analysis of the Femoral Acetabular Impingement Trial (FAIT). Outcome of interest: PainDETECT questionnaire; secondary outcomes of interest; International Hip Outcome Tool (iHOT33), Hospital Anxiety and Depression Scale (HADS) and VAS 'average pain over a month', at baseline and 8 months follow-up. Intervention (surgery or physiotherapy) were pooled.

RESULTS

173 data sets at baseline; 123 at 8 months follow-up. Baseline painDETECT identified three groups: 69% nociceptive, 19% unclear and 12% neuropathic pain phenotypes. Baseline, median scores were higher for the neuropathic group compared to the nociceptive group demonstrating borderline anxiety (9.5(5.3 to 14.2), 5(3 to 8), higher normal values for depression (7.5(2.3 to 11.8), (4(2 to 9), higher average pain (7 (6 to 8), 5(4 to 6) and lower iHOT33 14.2(9 to 21.1), 38.4(26.2 to 55.7). Post treatment, there was a median change in the neuropathic score in both iHOT33 (40.8 (25 to 76.5) with a median difference of 24.13 (CI 95% 10.46 to 45.92) and average pain 4.5(1.5 to 7) with a median difference of 2 (CI 95% 1 to 5) but to a lesser amount than the nociceptive group, iHOT33 (64(38.2 to 86.6) with a median difference of 15.50 (CI 95% 6.41 to 21.82) and average pain 3(1 to 5.7) with a median difference of 1 (CI 95% 0.5 to 1).

CONCLUSION

NeP exists in symptomatic FAIS patients and is associated with increased average pain, and functional limitations. Nociceptive-targeted treatment improves hip function and pain but with less improvement in the NeP group when compared to the nociceptive group. Pain phenotyping before intervention may improve outcomes. CONTRIBUTION OF PAPER.

Scores and sores: Exploring patient-reported outcomes for knee evaluation in orthopaedics, sports medicine and rehabilitation

Recognizing and addressing the controversies surrounding using patient-reported outcome measures (PROMs) is crucial for enhancing evaluation standards in clinical studies in orthopedics, sports medicine, and rehabilitation. The article comprehensively described the challenges of using PROMs to evaluate knee conditions in these fields. Apart from defining and characterizing patient-reported outcomes and their measures, the article discussed controversies around them, such as using them as primary outcomes. It highlighted the importance of standardizing and validating PROMs. Several initiatives taken to improve the selection of appropriate outcomes for clinical research purposes were described. Additionally, the potential of technology, mainly digital health tools and mobile applications, was mentioned in the context of enhancing the collection and analysis of PROMs. The article also raised the issue of the readability of PROMs, defined as the ease with which they can be read and understood by patients. The article concluded that adopting a complementary approach to treatment evaluation by integrating subjective and objective measures is imperative for accurately assessing efficacy. This comprehensive approach provides a more holistic understanding of patient outcomes, forms the foundation for evidence-based medicine, and informs future healthcare policies. Proactive measures are urgently needed to address concerns and improve the reliability and validity of PROMs for clinical practice and research. LEVEL OF EVIDENCE: level V.

Clinical Equipoise in the Management of Patients With Femoroacetabular Impingement Syndrome and Concomitant Tönnis Grade 2 Hip Osteoarthritis or Greater: An International Expert-Panel Delphi Study

PURPOSE

To gather global-expert opinion on the management of patients with femoroacetabular impingement syndrome (FAIS) and Tönnis grade 2 hip osteoarthritis (OA) or greater.

METHODS

An internet-based modified Delphi methodology was used via an online platform (Online Surveys) using the CREDES (Conducting and Reporting Delphi Studies) guidelines. The expert panel comprised 27 members from 18 countries: 21 orthopaedic surgeons (78%), 5 physiotherapists (18%), and 1 dual orthopaedic surgeon-sport and exercise medicine physician (4%). Comments and suggestions were collected during each round, and amendments were performed for the subsequent round. Between each pair of rounds, the steering panel provided the experts with a summary of results and amendments. Consensus was set a priori as minimum agreement of 80%.

RESULTS

Complete participation (100%) was achieved in all 4 rounds. A final list of 10 consensus statements was formulated. The experts agreed that there is no single superior management strategy for FAIS with Tönnis grade 2 OA and that Tönnis grade 3 OA and the presence of bilateral cartilage defects (acetabular and femoral) is a contraindication for hip preservation surgery. Nonoperative management should include activity modification and physiotherapy with hip-specific strengthening, lumbo-pelvic mobility training, and core strengthening. There was no consensus on the need for 3-dimensional imaging for initial quantification of joint degeneration.

CONCLUSIONS

There is clinical equipoise in terms of the best management strategy for patients with FAIS and Tönnis grade 2 OA, and therefore, there is an urgent need to perform a randomized controlled trial for this cohort of patients to ascertian the best management strategy.

LEVEL OF EVIDENCE

Level V, expert opinion.

Will you get what you want? Treatment goals and expectations of patients with femoroacetabular impingement syndrome regarding physiotherapist-led treatment

OBJECTIVE: To (i) investigate the goals and expectations of participants enrolled in a clinical trial of physiotherapist-led treatment for femoroacetabular impingement (FAI) syndrome and (ii) explore associations between their expectations and self-reported hip burden and kinesiophobia. METHODS: Data from 150 participants with FAI syndrome who participated in a clinical trial were analysed. Participants described their most important treatment goal and the expectation of achieving this goal throughout physiotherapy treatment. The International Hip Outcome Tool (iHOT-33) subscales were used to assess self-reported hip burden. The Tampa Scale for Kinesiophobia was used to assess kinesiophobia. Participants goals were qualitatively analysed using content analysis. Linear regression was used to explore associations between patient expectations and iHOT and Tampa Scale for Kinesiophobia scores. RESULTS: Participants with FAI syndrome reported goals relating to exercise (52%), improving activities of daily living quality (23%), improving physical function (15%), and reducing pain (10%). Negative expectations regarding physiotherapist-led treatment were reported by 68% of participants. Those with negative expectations reported worse scores for the iHOT-Total score (mean difference = 12 points, 95%CI = [4 to 19]), and iHOT-Symptoms (14 points, [7 to 21]) and iHOT-Social (11 points, [2 to 21]) subscales compared to those with positive expectations. Treatment expectations were not associated with iHOT-Sport, iHOT-Job, and Tampa Scale for Kinesiophobia scores (p > 0.05). CONCLUSION: Patients with FAI syndrome had a generally negative expectation of physiotherapist-led treatment. There was a mismatch between patients' goals and current treatment approaches. Participants with FAI syndrome and negative expectations reported worse quality of life, symptoms, and social concerns than those with positive expectations.

First-line treatment for femoroacetabular impingement syndrome and hip-related quality of life: study protocol for a multicentre randomised controlled trial comparing a 6-month supervised strength exercise intervention to usual care (the Better Hip Trial)

INTRODUCTION

Femoroacetabular impingement syndrome (FAIS) is a motion-related and position-related clinical condition of the hip associated with pain, reduced physical function and hip-related quality of life (QoL). Interestingly, higher maximal muscle strength is associated with less pain, better physical function and improved QoL in people with FAIS. Furthermore, preliminary evidence suggests that a proportion of patients with FAIS respond positively to strength exercise as first-line treatment. Nonetheless, there is little evidence supporting a specific exercise intervention offered as a first-line treatment. We will conduct a randomised controlled trial investigating the clinical effectiveness and cost-effectiveness of a 6-month strength exercise intervention compared with usual care as first-line treatment in patients with FAIS.

METHODS AND ANALYSIS

This is a multicentre randomised controlled trial that will be conducted at hospitals and physiotherapy clinics across Denmark and Australia. A total of 120 patients with FAIS will be randomised (1:1) to 6 months of supervised strength exercise or usual care. The primary outcome is the change in hip-related QoL measured using the International Hip and Outcome Tool 33 (iHOT-33) from baseline to the end of intervention. A health economic evaluation will be conducted from a societal and healthcare perspective based on the data collection over a 12-month period starting at baseline. The analysis will calculate incremental cost-effectiveness ratios using quality-adjusted life-years and iHOT-33 scores while estimating costs using microcosting and cost questionnaires. Secondary outcomes include objectively measured physical function at baseline and after 6 months and patient-reported outcomes measured at baseline, 3-month, 6-month and 12-month follow-up.

ETHICS AND DISSEMINATION

The trial has been approved by the Committee on Health Research Ethics in the Central Denmark Region (journal no 1-10-72-45-23) and La Trobe University Human Ethics Committee (HEC24042) and is registered at the Central Denmark Region List of Research Projects (journal no 1-16-02-115-23). Informed consent will be obtained from each participant before randomisation. Results will be published in international peer-reviewed scientific journals.

TRIAL REGISTRATION NUMBER

NCT05927935.

Femoroacetabular Impingement and the Effect of Osteochondroplasty on Hip Osteoarthritis Prevention: The Pandora's Box Opening Process

OBJECTIVE

This study was conducted to assess the effect of osteochondroplasty on osteoarthritis (OA) prevention, comparing radiological evolution between identical hips from the same patient who had undergone unilateral surgery.

DESIGN

We retrospectively reviewed radiological evolution between hips with similar shape from the same patient who had undergone unilateral surgery. In all, 56 FAI patients (112 hips) with a mean age of 42.18 ± 9.16 years and had undergone unilateral arthroscopy treatment have been included. Four independent researchers measured Wiberg, Acetabular and Alpha angles, Extrusion index, and Tönnis classification preoperatively to verify that operated and non-operated hips had the same shape. OA evolution was assessed by joint space width (JSW) in 3 different articular points and Tönnis classification.

RESULTS

No preoperative anatomical differences were present between groups (P > 0.05). At the end of follow-up (31.9 months), a decrease of JSW in the 3 points measured was found in OP hips (OP vs. N-OP; P < 0.01). These results were correlated with changes in the proportion of patients who progressed to grade III in Tönnis classification (from 1.3% preoperative to 23.2% at the end of follow-up).

CONCLUSIONS

Osteochondroplasty and labrum procedures were not associated with OA prevention. The OP hips showed a faster OA degeneration, which was not seen in the N-OP. These results will encourage hip surgeons to perform further investigations to avoid the "Pandora's Box Opening Process."

Hip Arthroscopy in Patients With Generalized Joint Hypermobility Yields Successful Outcomes: A Systematic Review

PURPOSE

To evaluate the outcomes of hip arthroscopy in patients with generalized joint hypermobility (GJH).

METHODS

A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses. An electronic record search was performed in PubMed, Web of Science, Cochrane Library, and Embase. A 2-stage title/abstract and full-text screening was performed using the following inclusion criteria: (1) observational studies, cohort studies, and randomized controlled trials; (2) describing more than 5 patients with a mean age over 18 years and GJH; (3) undergoing arthroscopy of the hip; (4) reporting patient-reported outcome measures (PROMs), return to sport, or complications/reoperations; and (5) published in English.

RESULTS

Of the 517 articles identified, 10 studies meeting all selection criteria were included. Included studies report significant improvements in a range of different functional and pain-based PROMs. Most patients (25.0%-97.0%) in each study achieved a clinically important improvement postoperatively in at least 1 PROM. No complications were described in any of the 4 studies reporting this metric. One study each found an association between GJH and an increased risk of postoperative deep gluteal syndrome and iliopsoas tendinitis. The rate of revision arthroscopy ranged from 0% to 11.4%, and only 2 patients in a single study of 11 hips required conversion to total hip arthroplasty. No statistically significant differences were reported between patients with and without GJH with respect to any of the described outcomes.

CONCLUSIONS

Patients with GJH may achieve good outcomes following hip arthroscopy with respect to PROMs, perioperative complications, reoperation, and return to sport. With effective labral repair and capsular closure, outcomes achieved in patients with GJH are comparable to those reported in patients without hypermobility.

LEVEL OF EVIDENCE

Level IV, systematic review of level III 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.

Demographic and Socioeconomic Patient Data Are Rarely Included in Randomized Controlled Trials for Femoral Acetabular Impingement and Hip Arthroscopy: A Systematic Review

Purpose

To determine the rate of reporting for sociodemographic variables in randomized controlled trials (RCTs) investigating femoral acetabular impingement (FAI) and hip arthroscopy.

Methods

PubMed, Scopus, and Web of Science were queried for articles relating to FAI and hip arthroscopy. Articles included in final analysis were RCTs investigating operative management of FAI. Included RCTs were analyzed for reporting of age and sex or gender as well as the following sociodemographic variables: race, ethnicity, insurance status, income, housing status, work status, and education level in the results section or any section of the paper. Data was analyzed using χ2 and Fisher exact tests with significance defined as P < .05.

Results

Forty-eight RCTs were identified from 2011 to 2023. Age was reported in 48 of 48 (100%) of included papers; sex or gender was reported in 47 of 48 (97.9%). Reporting of sociodemographic variables in any section respectively was: race (7/48, 14.6%), ethnicity (4/48, 8.33%), insurance status (0/48, 0%), income (1/48, 2.08%), housing status (0/48, 0%), work status (3/48, 6.25%), and education (2/48, 4.17%). There was no significant difference for reporting demographic variables with respect to journal or year of publication (P = .666 and P = .761, respectively). Sociodemographic variables (9/48) were reported significantly less frequently than age and sex or gender (48/48) (P < .001).

Conclusions

This study found that sociodemographic variables in FAI and hip arthroscopy RCTs are reported with much lower frequency than age and sex or gender. These findings may demonstrate the need to include patient sociodemographic data in RCTs so that their results can be better generalized and applied to the appropriate patient population.

Level of Evidence

Level II, systematic review of level I and II evidence.

Can intra-articular hip injections predict arthroscopy outcomes for femoroacetabular impingement syndrome? A systematic review

Background

Femoroacetabular Impingement (FAI) syndrome represents a prevalent aetiology of hip discomfort observed among both adolescent and adult populations. It is initially managed conservatively with oral anti-inflammatories and physiotherapy; some patients proceed to receiving an intra-articular (IA) hip injection, but ultimately, the gold-standard treatment is hip arthroscopy.

Study design

Systematic Review.

Purpose

To systematically investigate the relationship between response to IA anaesthetic or steroid hip injections and arthroscopy outcomes for FAI syndrome.

Methods

A systematic search of PubMed, Medline, CINAHL, SCOPUS, and Cochrane was conducted in line with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

Results

Seven studies (Level II-IV) were identified that met our inclusion and exclusion criteria. These studies collectively included 637 patients, demonstrating an average age of 37.5 years (and a range of 14-72 years). Two of the seven studies reported a statistically significant positive correlation between response to IA injections and arthroscopy outcomes. The remaining five studies found that although a positive IA injection response increased the odds of a good outcome post arthroscopy (defined across various studies as a post-operative modified Harris Hip score of >70 points, >79 points or an improvement by 8 or more points), this correlation was not statistically significant.

Conclusion

IA hip injections can be a useful prognostic tool, though they are not a consistently reliable predictor of which patients will have good arthroscopic outcomes.

Increased Duration and Intensity of Physical Activity Are Associated With Increased Pain in Individuals With Femoroacetabular Impingement Syndrome: An Ecological Momentary Assessment Study

OBJECTIVE

To investigate the relation between accelerometer-measured physical activity and real-time pain in individuals with femoroacetabular impingement syndrome (FAIS). We tested the hypothesis that increased duration of high intensity activity would contribute to momentary increases in pain.

DESIGN

Observational study.

SETTING

Participants' natural, day-to-day environment.

PARTICIPANTS

Population-based sample of 33 individuals with unilateral FAIS. Important eligibility criteria included no concomitant hip disorders or previous hip surgery. Key sociodemographic features include that all participants were required to have a smartphone.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Duration and intensity of physical activity as measured by a waist-worn accelerometer, and instantaneous pain reported in real-time smartphone-based ecological momentary assessment surveys. Physical activity variables included each person's average sedentary time, light physical activity (LPA), and moderate to vigorous physical activity (MVPA) in the 90 minutes proceeding all pain surveys as well as fluctuation in sedentary, LPA, and MVPA above or below average prior to each individual survey.

RESULTS

Linear mixed models revealed that the significant predictors of pain included fluctuation in sedentary time (B=-0.031, P<.001), average LPA (B=0.26, P=.035), and the interaction between fluctuation in LPA and fluctuation in MVPA (B=0.001, P<.001). Fluctuation in sedentary time above a person's average was associated with lower pain, while average LPA and fluctuations above average in both LPA and MVPA were associated with higher pain.

CONCLUSIONS

These results suggest that individuals with FAIS can engage in health-enhancing MVPA but should focus on avoiding concurrent increase above average in both high intensity and LPA in the same 90-minute period. Future work is warranted testing the efficacy of such an approach on pain. Additionally, given that high levels of LPA may arise from a host of socioeconomic factors, additional research is needed to disentangle the effect of LPA on pain in FAIS.

Can a clinical assessment predict the functional status progression in patients with femoroacetabular impingement syndrome?

BACKGROUND

Femoroacetabular impingement syndrome (FAIS) is a hip joint motion-related clinical disorder with a triad of symptoms, clinical signs, and imaging findings. However, scientific evidence is still unclear regarding the best treatment for FAIS.

OBJECTIVES

To assess the value of a physical therapy evaluation in predicting the progression of functional status over the subsequent years in patients with FAIS who are candidates for hip arthroscopy surgery.

METHODS

In this case-series study, patients with FAIS, candidates for hip arthroscopy surgery, underwent a standard physical therapy evaluation. Baseline data were collected between 2013 and 2019. In 2020/2021, the patients' functional status was assessed through the International Hip Outcome Tool (iHOT-33). Functional status progression was calculated as the difference between the follow-up and baseline iHOT-33 scores. A multivariate forward stepwise regression analysis was conducted to explore the relationship between baseline characteristics and the functional status progression.

RESULTS

From 353 patients who completed the baseline assessment, 145 completed the iHOT-33 follow-up. The mean (±SD) follow-up time was 58.7 (27.2) months (minimum 12 and maximum 103 months). The iHOT-33 scores increased 20.7 (21.8) points on average, ranging from -39.8 to 76.9 points. Among the 15 potential predictive factors assessed in this study, only baseline iHOT-33 score (β -0.44; -0.061, -0.27), femoral version (β 9.03; 1.36, 16.71), and body mass index (β -0.99; -1.98, -0.01) had the ability to predict the functional status progression.

CONCLUSION

Patients with a lower baseline iHOT-33 score, lower body mass index, and normal femoral version were more likely to increase their functional status after a minimum of one year of follow-up.

Predicting Outcomes in Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE OF REVIEW

Arthroscopic treatment of femoroacetabular impingement syndrome (FAIS) continues to rise in incidence, and thus there is an increased focus on factors that predict patient outcomes. The factors that impact the outcomes of arthroscopic FAIS treatment are complex. The purpose of this review is to outline the current literature concerning predictors of patient outcomes for arthroscopic treatment of FAIS.

RECENT FINDINGS

Multiple studies have shown that various patient demographics, joint parameters, and surgical techniques are all correlated with postoperative outcomes after arthroscopic FAIS surgery, as measured by both validated patient-reported outcome (PRO) scores and rates of revision surgery including hip arthroplasty. To accurately predict patient outcomes for arthroscopic FAIS surgery, consideration should be directed toward preoperative patient-specific factors and intraoperative technical factors. The future of accurately selecting patient predictors for outcomes will only improve with increased data, improved techniques, and technological advancement.

Which Acetabular Measurements Most Accurately Differentiate Between Patients and Controls? A Comparative Study

BACKGROUND

Acetabular morphology is an important determinant of hip biomechanics. To identify features of acetabular morphology that may be associated with the development of hip symptoms while accounting for spinopelvic characteristics, one needs to determine acetabular characteristics in a group of individuals older than 45 years without symptoms or signs of osteoarthritis. Previous studies have used patients with unknown physical status to define morphological thresholds to guide management.

QUESTIONS/PURPOSES

(1) To determine acetabular morphological characteristics in males and females between 45 and 60 years old with a high Oxford hip score (OHS) and no signs of osteoarthritis; (2) to compare these characteristics with those of symptomatic hip patients treated with hip arthroscopy or periacetabular osteotomy (PAO) for various kinds of hip pathology (dysplasia, retroversion, and cam femoroacetabular impingement); and (3) to assess which radiographic or CT parameters most accurately differentiate between patients who had symptomatic hips and those who did not, and thus, define thresholds that can guide management.

METHODS

Between January 2018 and December 2018, 1358 patients underwent an abdominopelvic CT scan in our institution for nonorthopaedic conditions. Of those, we considered 5% (73) of patients as potentially eligible as controls based on the absence of major hip osteoarthritis, trauma, or deformity. Patients were excluded if their OHS was 43 or less (2% [ 28 ]), if they had a PROMIS less than 50 (1% [ 18 ]), or their Tönnis score was higher than 1 (0.4% [ 6 ]). Another eight patients were excluded because of insufficient datasets. After randomly selecting one side for each control, 40 hips were left for analysis (age 55 ± 5 years; 48% [19 of 40] were in females). In this comparative study, this asymptomatic group was compared with a group of patients treated with hip arthroscopy or PAO. Between January 2013 and December 2020, 221 hips underwent hip preservation surgery. Of those, eight were excluded because of previous pelvic surgery, and 102 because of insufficient CT scans. One side was randomly selected in patients who underwent bilateral procedure, leaving 48% (107 of 221) of hips for analysis (age 31 ± 8 years; 54% [58 of 107] were in females). Detailed radiographic and CT assessments (including segmentation) were performed to determine acetabular (depth, cartilage coverage, subtended angles, anteversion, and inclination) and spinopelvic (pelvic tilt and incidence) parameters. Receiver operating characteristics (ROC) analysis was used to assess diagnostic accuracy and determine which morphological parameters (and their threshold) differentiate most accurately between symptomatic patients and asymptomatic controls.

RESULTS

Acetabular morphology in asymptomatic hips was characterized by a mean depth of 22 ± 2 mm, with an articular cartilage surface of 2619 ± 415 mm 2 , covering 70% ± 6% of the articular surface, a mean acetabular inclination of 48° ± 6°, and a minimal difference between anatomical (24° ± 7°) and functional (22° ± 6°) anteversion. Patients with symptomatic hips generally had less acetabular depth (20 ± 4 mm versus 22 ± 2 mm, mean difference 3 mm [95% CI 1 to 4]; p < 0.001). Hips with dysplasia (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 0% to 12%]; p = 0.03) or retroversion (67% ± 5% versus 70% ± 6%, mean difference 6% [95% CI 1% to 12%]; p = 0.04) had a slightly lower relative cartilage area compared with asymptomatic hips. There was no difference in acetabular inclination (48° ± 6° versus 47° ± 7°, mean difference 0.5° [95% CI -2° to 3°]; p = 0.35), but asymptomatic hips had higher anatomic anteversion (24° ± 7° versus 19° ± 8°, mean difference 6° [95% CI 3° to 9°]; p < 0.001) and functional anteversion (22° ± 6° versus 13°± 9°, mean difference 9° [95% CI 6° to 12°]; p < 0.001). Subtended angles were higher in asymptomatic at 105° (124° ± 7° versus 114° ± 12°, mean difference 11° [95% CI 3° to 17°]; p < 0.001), 135° (122° ± 9° versus 111° ± 12°, mean difference 10° [95% CI 2° to 15°]; p < 0.001), and 165° (112° ± 9° versus 102° ± 11°, mean difference 10° [95% CI 2° to 14°]; p < 0.001) around the acetabular clockface. Symptomatic hips had a lower pelvic tilt (8° ± 8° versus 11° ± 5°, mean difference 3° [95% CI 1° to 5°]; p = 0.007). The posterior wall index had the highest discriminatory ability of all measured parameters, with a cutoff value of less than 0.9 (area under the curve [AUC] 0.84 [95% CI 0.76 to 0.91]) for a symptomatic acetabulum (sensitivity 72%, specificity 78%). Diagnostically useful parameters on CT scan to differentiate between symptomatic and asymptomatic hips were acetabular depth less than 22 mm (AUC 0.74 [95% CI 0.66 to 0.83]) and functional anteversion less than 19° (AUC 0.79 [95% CI 0.72 to 0.87]). Subtended angles with the highest accuracy to differentiate between symptomatic and asymptomatic hips were those at 105° (AUC 0.76 [95% CI 0.65 to 0.88]), 135° (AUC 0.78 [95% CI 0.70 to 0.86]), and 165° (AUC 0.77 [95% CI 0.69 to 0.85]) of the acetabular clockface.

CONCLUSION

An anatomical and functional acetabular anteversion of 24° and 22°, with a pelvic tilt of 10°, increases the acetabular opening and allows for more impingement-free flexion while providing sufficient posterosuperior coverage for loading. Hips with lower anteversion or a larger difference between anatomic and functional anteversion were more likely to be symptomatic. The importance of sufficient posterior coverage was also illustrated by the posterior wall indices and subtended angles at 105°, 135°, and 165° of the acetabular clockface having a high discriminatory ability to differentiate between symptomatic and asymptomatic hips. Future research should confirm whether integrating these parameters when selecting patients for hip preservation procedures can improve postoperative outcomes.Level of Evidence Level III, prognostic study.

Both Labral Debridement and Labral Repair Result in >90% Total Hip Arthroplasty-free Survival at 5-Year Follow-Up: An Analysis of the German Cartilage Registry (KnorpelRegister DGOU)

PURPOSE

To compare clinical outcome parameters between labral debridement and repair by analyzing the dataset of a multinational registry.

METHODS

The data are based on the hip module of the German Cartilage Registry (KnorpelRegister DGOU). The register included patients designated for cartilage or femoroacetabular impingement surgery (up to July 1, 2021; n = 2725). The assessment consisted of the patient's characteristics, the type of labral treatment, the length of labral therapy, the pathology, the grade of cartilage damage, and the type of performed approach. The clinical outcomes were documented by the international hip outcome tool via an online platform. Separated Kaplan-Meier analyses were used for total hip arthroplasty (THA)-free survival rates.

RESULTS

The debridement group (n = 673) showed a mean score increase of 21.9 ± 25.3 points. The repair group (n = 963) had a mean improvement of 21.3 ± 24.6 (P > .05). The 60-month THA-free survival rate was 90% to 93% for both groups (P > .05). A multivariance analysis showed that the grade of cartilage damage was the only independent statistically significant factor (P = .002-.001) influencing patients' outcomes and THA-free survival.

CONCLUSIONS

Labral debridement and repair led to good and reliable results. However, these results should not be interpreted with the conclusion that the cheaper and technically easier labral debridement is the recommended treatment due to comparable results in the present study. The clinical outcome and the THA-free survival seemed to be more influenced by the grade of cartilage damage.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

The impact of surgical randomised controlled trials on the management of FAI syndrome: a citation analysis

PURPOSE

To identify and assess the clinical impact of randomised controlled trials (RCTs) assessing the surgical management of femoroacetabular impingement syndrome (FAIS) through a citation analysis.

METHODS

MEDLINE, EMBASE and CENTRAL were searched from inception to April 22, 2023 for RCTs assessing the surgical management of FAIS. Study characteristics were directly abstracted from included trials and citation metrics were obtained from the Clarivate Web of Knowledge database on May 19, 2023. The continuous fragility index (CFI) was calculated for eligible outcomes. Univariate regression models were used to explore correlations between total citations per year and various study characteristics.

RESULTS

Ten studies comprising one thousand two hundred ninetypatients were eligible for analysis. Studies were published from 2013 to 2023. Eight countries were represented across various trials with 91% being either North American or European. The mean journal impact factor of published studies was 39.684 (median 2.982; range 1.31-202.73). The mean citation density was 14.17 (range 0.33-48.67). The median CFI was 4.8 (range 1-32.2). Correlation analysis demonstrated strong and statistically significant correlations to study sample size (R = 0.75, p = 0.012), journal impact factor (R = 0.80, p = 0.006) and continuous fragility index (R = 0.95, p = 0.015).

CONCLUSION

Trials assessing the surgical management of FAIS present with a wide range of clinical uptake based on citation density and are published in journals of broadly variable impact factor. Despite promising citation metrics, high-quality evidence on arthroscopy for FAIS is limited to the United States and Europe with an unclear international impact. Future knowledge translation efforts are warranted to maximise the international uptake of evidence regarding arthroscopic management of FAIS.

LEVEL OF EVIDENCE

I.

Non-operative Management and Outcomes of Femoroacetabular Impingement Syndrome

PURPOSE

To serve as a guide for non-operative physicians in the management of femoroacetabular impingement syndrome and provide an algorithm as to when to refer patients for potential surgical management.

RECENT FINDINGS

Supervised physical therapy programs that focus on active strengthening and core strengthening are more effective than unsupervised, passive, and non-core-focused programs. There is promising evidence for the use of intra-articular hyaluronic acid and PRP as adjunct treatment options. Recent systematic reviews and meta-analyses have found that in young active patients, hip arthroscopy demonstrates improved short-term outcomes over physical therapy. The decision for the management of FAIS is complex and should be specific to each patient. Consideration of the patient's age, timing to return to sport, longevity of treatment, hip morphology, and degree of cartilage degeneration is required to make an informed decision in the treatment of these patients.

Does response to preoperative intra-articular anesthetic injections predict outcomes of femoroacetabular impingement syndrome?

INTRODUCTION

Some patients with femoroacetabular impingement syndrome (FAIS) who undergo surgery do not show satisfactory outcomes. Reliable tests that can inform prognosis of FAIS surgery are needed for optimized indications and contraindications to surgery. We aimed to review and critically appraise available literature on the capability of patient response to preoperative intra-articular anesthetic injections (PIAI) to predict post-surgical outcomes in patients with FAIS.

MATERIALS AND METHODS

This study was conducted in accordance with the PRISMA statement. Studies that assessed the patient pain response to PIAI and post-surgical outcomes in patients with FAIS were considered eligible. Study selection and data collection were performed by three independent reviewers. Main outcomes evaluated were those measured by hip outcome scales often used in assessing postoperative pain and functional recovery, such as the modified Harris Hip Score (mHHS) and international Hip Outcome Tool (iHOT). The likelihood ratio of achieving satisfactory postoperative outcomes at the mHHS (LHR) was extracted or calculated-for patients with significant response to PIAI and for those without a significant response to PIAI. The risk of bias was assessed using the Quality In Prognosis Studies (QUIPS) tool.

RESULTS

Six studies were considered eligible for analysis. Five studies indicated that patient response to PIAI are associated to surgical outcomes for patients with FAIS, with a greater reduction in pain typically indicating a better surgical outcome. Additionally, the LHR ranged from 1.15 to 1.92 for patients with significant response to PIAI (I2 = 90.6%). For patients without a significant response, the LHR ranged from 0.18 to 0.65 (I2 = 87.5). An overall high risk of bias was observed for all studies included in the analysis. Study attrition, the prognostic factor measurement and the presence of confounding factors were the main sources of bias.

CONCLUSIONS

Greater reductions in pain with preoperative intra-articular anesthetic injections were found to be associated to better outcomes after FAIS surgery, but all available studies contain a high risk of bias.

Efficacy and safety of arthroscopy in femoroacetabular impingement syndrome: a systematic review and meta-analysis of randomized clinical trials

This study aimed to compare the efficacy and safety of arthroscopy with physiotherapy or joint lavage in patients with femoroacetabular impingement (FAI). A meta-analysis using PubMed, Embase, Scopus, and the Cochrane Collaboration Library databases was performed in September 2022. We included studies focusing on patients with FAI who underwent arthroscopic surgery versus those who underwent physiotherapy or arthroscopic lavage. The outcomes were functional scores (iHOT-33 and HOS ADL) and adverse events. Randomized clinical trials were included in the study. The risk of bias in each study was assessed according to Cochrane guidelines for clinical trials. The data were combined using Review Manager version 5.4. (PROSPERO CRD42022375273). Six RCTs were included, from a pool of 839 patients (407 females). The iHOT-33 and HOS ADL scales showed significant differences at 12 months in favor of the arthroscopy group (MD, 10.65; 95% CI 6.54-4.76) and (MD, 8.09; 95% CI 3.11-13.07). MCID was not achieved through arthroscopy in functional variables. The rates of osteoarthritis (OR, 6.18; 95% CI 1.06-36.00) and numbness (OR, 73.73; 95% CI 10.00-43.92) were significantly higher in the arthroscopy group. Arthroscopic surgery showed statistical superiority over the control group without exceeding the MCID in most studies; however, the results might have been influenced by secondary variables. Finally, arthroscopic surgery results in a high rate of conversion to osteoarthritis.

Clinical Commentary: A Criteria-Based Testing Protocol for Return to Sport Post Hip Arthroscopy for Impingement

Overall, 84%-87% of athletes will return to sport following hip arthroscopy; however, some literature suggests that only 57% of athletes return to their preinjury level, and only 16.9% report optimal performance. This discrepancy may be due to a lack of consistency within the definition of return to sport as well as a lack of consistency within rehabilitation programs when determining return to sport readiness. Athletes who are returning to sport must demonstrate adequate range of motion, strength, and the ability to perform multi-directional movements without the risk of reinjury. There has yet to be a comprehensive, criteria-based, return to sport testing protocol that utilizes objective measures to ensure athletes are ready for return to sport. The goal of the authors was to create a criteria-based testing protocol for return to sport following hip arthroscopy utilizing components best supported in the literature. The following parameters were identified as key areas to assess for within a return to sport testing protocol: range of motion, strength, functional testing, self-reported outcomes including psychological readiness and time. The purpose of this clinical commentary is to propose a criteria-based testing protocol to be used following hip arthroscopy for impingement from early rehabilitation through return to previous level of sport. Criteria are presented clearly to promote objective progression through rehabilitation while still being mindful of the biological healing time required for safe and efficient progression. It is the authors' hope that in identifying and establishing a criteria-based testing protocol a higher percentage of athletes will be able to return to sport.

Level of Evidence

5.

Postoperative Rehabilitation for Arthroscopic Management of Femoroacetabular Impingement Syndrome: a Contemporary Review

PURPOSE OF REVIEW

Femoroacetabular impingement syndrome (FAIS) is a common cause of hip pain that may potentially lead to osteoarthritis. Operative management of FAIS seeks to arthroscopically reshape the abnormal hip morphology and repair the labrum. For rehabilitation following operative management, a structured physical therapy program is unanimously recommended for the patient to return to their previous level of physical activity. Yet, despite this unanimous recommendation, significant heterogeneity exists among the current recommendations for postoperative physical therapy programs.

RECENT FINDINGS

A four-phase postoperative physical therapy protocol is favored among current literature, with each phase being comprised of its own goals, restrictions, precautions, and rehabilitation techniques. Phase 1 aims to protect the integrity of the surgically repaired tissues, reduce pain and inflammation, and regain ~ 80% of full ROM. Phase 2 guides a smooth transition to full weightbearing, so the patient may regain functional independence. Phase 3 helps the patient become recreationally asymptomatic and restores muscular strength and endurance. Finally, phase 4 culminates in the pain-free return to competitive sports or recreational activity. At this time, there exists no single, unanimously agreed upon postoperative physical therapy protocol. Among the current recommendations, variation exists regarding specific timelines, restrictions, precautions, exercises, and techniques throughout the four phases. It is imperative to reduce ambiguity in current recommendations and more specifically define postoperative physical therapy following operative management of FAIS to more expeditiously return patients to functional independence and physical activity.

Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models

OBJECTIVE

Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state.

METHODS

Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019).

RESULTS

The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination.

CONCLUSION

Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

Outcomes of arthroscopy of the hip for femoroacetabular impingement based on intraoperative assessment using the Outerbridge classification

Aims

Hip arthroscopy (HA) has become the treatment of choice for femoroacetabular impingement (FAI). However, less favourable outcomes following arthroscopic surgery are expected in patients with severe chondral lesions. The aim of this study was to assess the outcomes of HA in patients with FAI and associated chondral lesions, classified according to the Outerbridge system.

Methods

A systematic search was performed on four databases. Studies which involved HA as the primary management of FAI and reported on chondral lesions as classified according to the Outerbridge classification were included. The study was registered on PROSPERO. Demographic data, patient-reported outcome measures (PROMs), complications, and rates of conversion to total hip arthroplasty (THA) were collected.

Results

A total of 24 studies were included with a total of 3,198 patients (3,233 hips). Patients had significantly less improvement in PROMs if they had Outerbridge grade III and IV lesions (p = 0.012). Compared with microfracture, autologous matrix-induced chondrogenesis (AMIC) resulted in significantly reduced rates of conversion to THA (p = 0.042) and of revision arthroscopy (p = 0.038). Chondral repair procedures in these patients also did not significantly reduce the rates of conversion to THA (p = 0.931), or of revision arthroscopy (p = 0.218). However, compared with microfracture, AMIC significantly reduced the rates of conversion to THA (p = 0.001) and of revision arthroscopy (p = 0.011) in these patients. Those with Outerbridge grade III and IV lesions also had significantly increased rates of conversion to THA (p = 0.029) and of revision arthroscopy (p = 0.023) if they had associated lesions of the acetabulum and femoral head. Those who underwent labral debridement had a significantly increased rate of conversion to THA compared with those who underwent labral repair (p = 0.015).

Conclusion

There is universal improvement in PROMs following HA in patients with FAI and associated chondral lesions. However, those with Outerbridge grade III and IV lesions had significantly less improvement in PROMs and a significantly increased rate of conversion to THA than those with Outerbridge grade I and II. This suggests that the outcome of HA in patients with FAI and severe articular cartilage damage may not be favourable.

A Genome-Wide Association Study Meta-Analysis of Alpha Angle Suggests Cam-Type Morphology May Be a Specific Feature of Hip Osteoarthritis in Older Adults

OBJECTIVE

To examine the genetic architecture of cam morphology using alpha angle (AA) as a proxy measure and conduct an AA genome-wide association study (GWAS) followed by Mendelian randomization (MR) to evaluate its causal relationship with hip osteoarthritis (OA).

METHODS

Observational analyses examined associations between AA measurements derived from hip dual x-ray absorptiometry (DXA) scans from the UK Biobank study and radiographic hip OA outcomes and subsequent total hip replacement. Following these analyses, an AA GWAS meta-analysis was performed (N = 44,214) using AA measurements previously derived in the Rotterdam Study. Linkage disequilibrium score regression assessed the genetic correlation between AA and hip OA. Genetic associations considered significant (P < 5 × 10-8 ) were used as AA genetic instrument for 2-sample MR analysis.

RESULTS

DXA-derived AA showed expected associations between AA and radiographic hip OA (adjusted odds ratio [OR] 1.63 [95% confidence interval (95% CI) 1.58, 1.67]) and between AA and total hip replacement (adjusted hazard ratio 1.45 [95% CI 1.33, 1.59]) in the UK Biobank study cohort. The heritability of AA was 10%, and AA had a moderate genetic correlation with hip OA (rg  = 0.26 [95% CI 0.10, 0.43]). Eight independent genetic signals were associated with AA. Two-sample MR provided weak evidence of causal effects of AA on hip OA risk (inverse variance weighted OR 1.84 [95% CI 1.14, 2.96], P = 0.01). In contrast, genetic predisposition for hip OA had stronger evidence of a causal effect on increased AA (inverse variance weighted β = 0.09 [95% CI 0.04, 0.13], P = 4.58 × 10-5 ).

CONCLUSION

Expected observational associations between AA and related clinical outcomes provided face validity for the DXA-derived AA measurements. Evidence of bidirectional associations between AA and hip OA, particularly for risk of hip OA on AA, suggests that hip shape modeling secondary to a genetic predisposition to hip OA contributes to the well-established relationship between hip OA and cam morphology in older adults.

Arthroscopic Decompression of the Anterior Inferior Iliac Spine

Background

Pathologic contact between the femoral neck and anterior inferior iliac spine (AIIS or subspine) often occurs concomitantly with femoroacetabular impingement, contributing to hip pain and dysfunction1-4. We perform arthroscopic AIIS decompression to alleviate this source of extra-articular impingement and eliminate a potential cause of persistent pain following primary hip arthroscopy5-7.

Description

After identifying abnormal AIIS morphology on preoperative false-profile radiographs and/or 3D computed tomography, we utilize a beaver blade to make a small incision in the proximal capsule and rectus femoris tendon. This peri-capsulotomy window grants access to the subspine region. We then shuttle an arthroscopic burr into place within this window and begin debriding the subspine deformity under direct visualization. Fluoroscopy is utilized intraoperatively to ensure adequate resection, using intraoperative false-profile views achieved by canting the C-arm approximately 40°. Resection is considered adequate when the AIIS deformity is no longer readily apparent on false-profile views and when intraoperative range-of-motion testing confirms no further impingement with hip hyperflexion.

Alternatives

Femoroacetabular impingement can be treated nonoperatively with use of physical therapy and activity modification8; however, outcomes following nonoperative treatment are inferior to those following hip arthroscopy, according to various studies9-12. There are no known alternative treatments specific to subspine impingement.

Rationale

As patients with subspine deformities progress through hip flexion, the femoral neck collides with the AIIS, limiting range of motion. As such, subspine deformities have been shown to be more common in dancers and other high-flexion athletes13,14. Additionally, studies have demonstrated that low femoral version of <5° is associated with increased contact between the distal femoral neck and the AIIS. This pathologic contact can occur even in the absence of an obvious subspine deformity15. In both of these patient populations, surgeons should have a high suspicion for subspine impingement, and a subspine decompression should be performed during hip arthroscopy in order to maximize patient outcomes.

Expected Outcomes

This is a safe procedure that, if performed when indicated, can improve outcomes following primary hip arthroscopy. A recent systematic review found a pooled complication risk of 1.1%, a pooled revision risk of 1.0%, and significant postoperative improvements in patient-reported outcome measures16.

Important Tips

Suspect subspine impingement in high-flexion athletes and patients with low femoral version, even in the absence of an obvious deformity.Ensure adequate visualization of the entire subspine deformity by creating a pericapsular window.Confirm thorough resection with use of fluoroscopic imaging intraoperatively, including false-profile views demonstrating absent subspine deformity.

Acronyms and Abbreviations

FAI = femoroacetabular impingementAP = anteroposterior, refers to the technique used to obtain one of the pelvic radiographs3D CT = three-dimensional computed tomographyLCEA = lateral center-edge angle, a measurement used to quantify severity of hip dysplasiaOR = operating roomAlpha = alpha angle, a measurement used to measure femoral head-neck offset and assess the severity of a cam deformityIc = iliocapsularisRFd = direct head of rectus femorisRFr = reflected head of rectus femorisCap = hip capsuleGMi = gluteus minimusmHHS = modified Harris Hip ScoreHOS-ADL = Hip Outcome Score - Activities of Daily LivingHOS-SSS = Hip Outcome Score - Sports Specific Subscale.

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

BACKGROUND

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

PURPOSE

To evaluate outcomes after arthroscopic AIIS decompression.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

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

RESULTS

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

CONCLUSION

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

Editorial Commentary: Hip Arthroscopy in Patients With Moderate to Advanced Osteoarthritis Shows Unpredictable Results

Hip arthroscopy is an effective surgical approach for the treatment of femoroacetabular impingement (FAI) syndrome with concomitant mild hip osteoarthritis (OA). However, in the FAI patients with moderate to advanced hip OA (Tönnis grade 2 or greater), whether hip arthroscopy could provide symptomatic relief or delay the need for an ultimate total hip arthroplasty surgery is controversial. The literature is heterogeneous and of generally lower quality evidence. Recent research reporting 10-year outcomes of hip arthroscopy in patients with hip OA shows 57% survivorship, and 78% survivor satisfaction. With unpredictable results, surgeons and well informed patients could hold some hope for a positive outcome after arthroscopy of an arthritic hip. As the Tönnis grading system shows poor interobserver reliability, surgeons may need to carefully consider their personal indications and resultant outcomes.

Gluteal activation during squatting reduces acetabular contact pressure in persons with femoroacetabular impingement syndrome: A patient-specific finite element analysis

BACKGROUND

Femoroacetabular impingement syndrome is a motion-related clinical disorder resulting from abnormal hip joint morphology. Mechanical impingement, in which the aspherical femoral head (cam morphology) abuts with the acetabular rim, is created with simultaneous hip flexion, internal rotation, and adduction. Impaired function of the gluteal muscles may be contributory to femoroacetabular impingement syndrome progression. The purpose of this study was to assess the influence of gluteal muscle recruitment on acetabular contact pressure during squatting in persons with cam femoroacetabular impingement syndrome.

METHODS

Eight individuals (4 males, 4 females) with a diagnosis of cam femoroacetabular impingement syndrome underwent CT imaging of the pelvis and proximal femora, and a biomechanical assessment of squatting (kinematics, kinetics, and electromyography). Two maximal depth bodyweight squat conditions were evaluated: 1) non-cued squatting; and 2) cued gluteal activation squatting. Utilizing subject-specific electromyography-driven hip and finite element modeling approaches, hip muscle activation, kinematics, bone-on-bone contact forces, and peak acetabular contact pressure were compared between squat conditions.

FINDINGS

Modest increases in gluteus maximus (7% MVIC, P < 0.0001) and medius (6% MVIC, P = 0.009) activation were able to reduce hip internal rotation on average 5° (P = 0.024), and in doing so reduced acetabular contact pressure by 32% (P = 0.023). Reductions in acetabular contact pressure occurred despite no change in hip abduction and increased bone-on-bone contact forces occurring in the cued gluteal activation condition.

INTERPRETATION

Our findings highlight the importance of gluteal activation in minimizing mechanical impingement and provide a foundation for interventions aimed at preventing the development and progression of femoroacetabular impingement syndrome.

Hip Arthroscopy With Bone Marrow Aspirate Injection for Patients With Symptomatic Labral Tears and Early Degenerative Changes Shows Similar Improvement Compared With Patients Undergoing Hip Arthroscopy With Symptomatic Labral Tears Without Arthritis

PURPOSE

To define the clinical effect of intra-articular injection of iliac crest-derived bone marrow aspirate concentrate (BMAC) at the time of hip arthroscopy in patients with symptomatic labral tears and early radiographic degenerative changes.

METHODS

A retrospective review of a prospectively collected hip registry database was performed. Patients with symptomatic labral tears and Tönnis grade 1 or 2 degenerative changes who underwent labrum-preserving hip arthroscopy with BMAC injection were included and were matched with patients who underwent hip arthroscopy without BMAC injection. Patient-reported outcomes (PROs) collected preoperatively and up to 2 years postoperatively included the modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sport, and International Hip Outcome Tool 33 score. Clinical relevance was measured with the minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit for each outcome score.

RESULTS

A total of 35 patients underwent labrum-preserving hip arthroscopy with BMAC injection and were matched with 35 control patients. There were no differences in demographic characteristics between the groups (P > .05). The BMAC group consisted of 22 patients (62.9%) with Tönnis grade 1 changes and 13 (37.1%) with Tönnis grade 2 changes, whereas all 35 control patients had Tönnis grade 0 hips. All PROs were significantly improved in both groups at 2 years, with no difference in improvement. The rate of failure requiring conversion to total hip arthroplasty was 14.3% (mean, 1.6 years postoperatively) in the BMAC group and 5.7% (mean, 7 years postoperatively) in the control group (P = .09). The difference in the frequency of patients achieving the minimal clinically important difference, patient acceptable symptom state, and substantial clinical benefit was not statistically significant between cohorts.

CONCLUSIONS

In a challenging group of patients with symptomatic labral tears and early radiographic degenerative changes, hip arthroscopy with BMAC injection results in statistically and clinically significant improvement in PROs comparable to a group of patients with nonarthritic hips undergoing hip arthroscopy at short-term follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

No evidence exists on outcomes of non-operative management in patients with femoroacetabular impingement and concomitant Tönnis Grade 2 or more hip osteoarthritis: a scoping review

PURPOSE

The purpose of this scoping review was to assess the outcomes of all the non-operative modalities of management for femoroacetabular impingement (FAI) and concomitant osteoarthritis (OA) Tönnis Grade 2 or more.

METHODS

A systematic search of PubMed was performed from inception to December 1st 2021 for literature on outcomes of non-operative management strategies for young adults with symptomatic FAI using the PRISMA Extension for Scoping Reviews guidelines. Cohorts investigating FAI and concomitant hip OA Tönnis Grade 2 or more were considered eligible. Studies not written in English or German, below level 4 evidence, and reviews were excluded. A secondary analysis for FAI without OA stratification was conducted after the initial screening to allow identification of available non-operative interventions.

RESULTS

No study reported outcomes separately for non-operative management of FAI with Tönnis Grade 2 OA or more and as such, did not fulfil the inclusion criteria. A secondary analysis included 24 studies that reported on outcomes for non-operative interventions for FAI irrespective of the degree of degeneration. Three studies investigated the efficacy of hyaluronic acid injection, 5 reports investigated corticosteroid injections, 2 studies evaluated the outcomes of hip bracing and 16 studies included a physiotherapy programme. Associations between the aforementioned interventions were analysed. There is level I evidence supporting the efficacy of activity modification and hip-specific physiotherapy for FAI and mild OA. Core-strengthening exercises are prevalent amongst successful regimens in the literature. Contradictory evidence questions the efficacy of hip bracing even for short-term outcomes. Corticosteroid injections have mostly failed in intention-to treat analyses but may be valuable in delaying the need for surgery; further studies are warranted. Reports on outcomes following hyaluronic acid injections are contradictory.

CONCLUSION

No evidence exists on outcomes following non-operative management of FAI with concomitant Tönnis Grade 2 or more OA of the hip. Further studies are required and should explore the non-operative interventions that were employed for FAI and milder OA. There is strong evidence for a hip-specific physiotherapy program including activity modification and core strengthening exercises. Adjunct interventions such as corticosteroid injections and NSAID consumption may be valuable in delaying the need for surgery.

LEVEL OF EVIDENCE

Level IV.

Defining Parameters for Surgical Correction and Hip Complications for Femoroacetabular Impingement Syndrome: Results of an International Modified Delphi Study

OBJECTIVES

To develop recommendations for clinical and radiographic criteria to help define the "acceptable" surgical correction of femoroacetabular impingement syndrome (FAIS) and identify/define complications postoperatively.

METHODS

A 3-phase modified Delphi study was conducted involving a case-based survey; a Likert/multiple choice-based survey concerning radiographic and physical examination characteristics to help define FAIS correction, as well as the prevalence and definition of potential postoperative complications; and 2 consensus meetings.

RESULTS

Of the 75 experts invited, 54 completed the Phase I survey, 50 completed the Phase II survey (72% and 67% response rate), and 50 participated in the Phase III consensus meetings. For both typical and atypical (complex) cases, there was consensus that fluoroscopy with multiple views and dynamic hip assessment should be used intraoperatively (96% and 100%, respectively). For typical FAIS cases, the Expert Panel agreed that Dunn lateral and anteroposterior radiographs were the most important radiographs to evaluate the hip postoperatively (88%, consensus). When asked about evaluating the correction of cam impingement postoperatively, 87% voted that they use subjective evaluation of the "sphericity" of the femoral head. In the case of focal and global pincer-type FAIS, there was consensus that the reduction or elimination of the crossover sign (84%) and lateral center-edge angle (91%) were important to inform the extent of the FAIS correction. There was consensus for recommending further investigation at 6 months postoperatively if hip pain had increased/plateaued (92% agreed); that additional investigation and treatment should occur between 6 and 12 months (90% agreed); and that a reoperation may be recommended at 12 months or later following this investigation period (89% agreed).

CONCLUSIONS

This consensus project identified the importance of using fluoroscopy and dynamic hip assessment intraoperatively; Dunn lateral and anteroposterior view radiographs postoperatively; evaluating the "sphericity" of the femoral head for cam-type correction and the use of dynamic hip assessment; reducing/eliminating the crossover sign for focal pincer-type FAIS; evaluating the lateral center-edge angle for global pincer-type FAIS; and avoiding overcorrection of pincer-type FAIS. In cases in which postoperative hip pain increased/plateaued, further investigation and treatment is warranted between 6 and 12 months, and a reoperation may be recommended at a minimum of 12 months depending on the cause of the hip pain.

CLINICAL RELEVANCE

Hip arthroscopy surgeons have yet to reach a firm agreement on what constitutes an "acceptable" or "good" surgery radiographically and how they can achieve desired clinical outcomes. Although this was a comprehensive effort, more study is needed to determine therapeutic thresholds that can be universally applied.

Evolution of Hip Muscles Strength in Femoroacetabular Impingement Patients Treated by Arthroscopy or Surgical Hip Dislocation: A Retrospective Exploratory Study

Hip arthroscopy and surgical hip dislocation (SHD) can be adequate surgical options for patients suffering from femoroacetabular impingement (FAI) syndrome, but there is to date no published data on their impact on hip muscles strength. The purpose of this retrospective study was, therefore, to evaluate it on a consecutive series of 50 FAI patients treated either by arthroscopy (n = 29, aged 27.4 ± 7.5 years, 76% of women) or SHD (n = 21, aged 25.9 ± 6.5 years, 38% of women) at La Tour Hospital between 2020 and 2021. The bilateral isometric strengths of eight hip-related muscles were evaluated before and three months after surgery (halfway through the rehabilitation program). For arthroscopy, a statistically significant (p < 0.05) reduction in hip muscles strength could be noted on the operated hamstrings (1.49 ± 0.43 vs. 1.39 ± 0.38 Nm/kg), flexors (1.88 ± 0.46 vs. 1.73 ± 0.41 Nm/kg), abductors (1.97 ± 0.42 vs. 1.72 ± 0.40 Nm/kg) and external rotators (1.17 ± 0.40 vs. 1.04 ± 0.37 Nm/kg). The abductors were the most affected muscles, with 45% of the patients suffering from a strength reduction ≥15%. The non-operated external rotators were also affected but to a lesser extent (1.21 ± 0.38 vs. 1.10 ± 0.36 Nm/kg). For SHD, a statistically significant strength reduction could be noted on the operated extensors (2.28 ± 0.84 vs. 2.05 ± 0.70 Nm/kg), abductors (1.87 ± 0.49 vs. 1.65 ± 0.41 Nm/kg), quadriceps (2.96 ± 0.92 vs. 2.44 ± 0.89 Nm/kg), external rotators (1.16 ± 0.42 vs. 0.93 ± 0.36 Nm/kg) and internal rotators (1.26 ± 0.38 vs. 0.96 ± 0.30 Nm/kg). The internal rotators were the most affected muscles, with 75% of the patients suffering from a strength reduction ≥15%. To conclude, particular attention should be paid to operated abductors for patients treated by arthroscopy as well as operated internal/external rotators, abductors and quadriceps for those treated by surgical hip dislocation. It reinforces that a rehabilitation method based on isolated muscle reinforcement and functional exercises that goes beyond three postoperative months is needed.

Oxford consensus on primary cam morphology and femoroacetabular impingement syndrome: part 2-research priorities on conditions affecting the young person's hip

INTRODUCTION

Primary cam morphology is highly prevalent in many athlete populations, causing debilitating hip osteoarthritis in some. Existing research is mired in confusion partly because stakeholders have not agreed on key primary cam morphology elements or a prioritised research agenda. We aimed to inform a more rigorous, inclusive and evidence-based approach to research on primary cam morphology and its natural history by working towards agreement on a set of research priorities for conditions affecting the young person's hip.

METHODS

An international expert panel-the Young Athlete's Hip Research (YAHiR) Collaborative-rated research priority statements through an online two-round Delphi exercise and met online to explore areas of tension and dissent. Panellists ranked the prioritised research statements according to the Essential National Health Research (ENHR) ranking strategy. Reporting of results followed REPRISE (REporting guideline for PRIority SEtting of health).

RESULTS

A diverse Delphi panel (n=65, Delphi rounds 1 and 2; three ENHR strategy surveys: n=49; n=44; n=42) from 18 countries representing six stakeholder groups, prioritised and ranked 18 of 38 research priority statements. The prioritised statements outlined seven research domains: (1) best practice physiotherapy, (2) rehabilitation progression and return to sport, (3) exercise intervention and load management, (4) primary cam morphology prognosis and aetiology, (5) femoroacetabular impingement syndrome prognosis and aetiology, (6) diagnostic criteria, and (7) screening. The panel recommended areas of tension and dissent for the research community to focus on immediately.

CONCLUSION

While informing more rigorous, inclusive and evidence-based research, this consensus is a roadmap for researchers, policy-makers and funders to implement research dedicated to reducing the cost and burden of hip disease related to primary cam morphology.

An all-arthroscopic light bulb technique to treat osteonecrosis of the femoral head through outside-in fashion without distraction: A case report

The technique of distraction has been widely used in hip arthroscopy for opening joint spaces. However, an all-arthroscopic light bulb technique through outside-in fashion without distraction has not been reported for the treatment of osteonecrosis of the femoral head (ONFH). A 29-year-old man was admitted to our department with hip pain and limited range of motion (ROM) in both hips over 4 months. X-rays, computed tomography (CT), and magnetic resonance imaging (MRI) showed a mixed appearance, including sclerosis and cysts on the anterosuperior site of the bilateral femoral heads. The patient had an 11-year history of liquor intake. In addition, no other pathologies were found before the operation. After diagnosing bilateral ONFH (stage II) according to the Ficat classification, the patient underwent an all-arthroscopic light bulb technique through outside-in fashion without distraction because of failing conservative treatment. At the 2-year postoperative follow-up, the patient had neither pain nor limitation of ROM. The postoperative x-ray, CT, and MRI revealed a well-healed area of the previous bone grafting in the bilateral femoral heads. An all-arthroscopic light bulb technique through outside-in fashion without distraction can be a feasible method for the treatment of early-stage ONFH. This case reminds us that distraction- and perforation-related complications may be avoided in patients with ONFH without the concomitant pathologies of the central compartment.

Conservative vs. Surgical Management for Femoro-Acetabular Impingement: A Systematic Review of Clinical Evidence

Femoro-acetabular impingement (FAI) syndrome is one of the most studied conditions in sports medicine. Surgical or conservative approaches can be proposed for treating FAI, although the best standard of care is not established yet. Our aim is to provide a comprehensive review of the best treatment for FAI syndrome evaluating differences in outcomes between surgical and non-operative management. A literature search was carried out on the PubMed, EMBASE, Scopus, and PEDro databases, using the following keywords: "femoroacetabular impingement", "FAI", in association with "surgery", "arthroscopy", "surgical" and "conservative", "physiotherapy", "physical therapy", "rehabilitation", "exercise". Only Level I RCTs were included. Four articles were selected for this systematic review. Our analysis showed different therapeutic protocols, follow-up periods, and outcomes; however, three out of the four studies included favored surgery. Our study demonstrates beneficial effects for both arthroscopic treatment and a proper regimen of physical therapy, nevertheless a surgical approach seemed to offer superior short-term results when compared to conservative care only. Further trials with larger sample sizes and longer follow-ups are needed to assess the definitive approach to the FAI condition.

Depression and anxiety are associated with worse baseline function in hip arthroscopy patients

PURPOSE

The purpose of this study was to analyze the correlation between baseline depression and anxiety and preoperative functional status in hip arthroscopy patients.

METHODS

A prospective, institutional review board-approved orthopaedic registry was used to retrospectively study 104 patients undergoing hip arthroscopy. Enrolled patients were administered baseline questionnaires for Patient-Reported Outcomes Measurement Information System (PROMIS) domains, Musculoskeletal Outcomes Data Evaluation and Management System (MODEMS) preoperative expectations, and Numeric Pain Scale (NPS).

RESULTS

The average baseline PROMIS Depression and Anxiety scores were 49.9 ± 9.8 and 55.5 ± 9.3, respectively. Bivariate analysis demonstrated that greater baseline PROMIS Anxiety correlated with worse preoperative PROMIS PI (p < 0.001), Fatigue (p < 0.001), Social Satisfaction (p < 0.001), and NPS score (p = 0.013). Bivariate analysis showed that greater PROMIS Depression correlated with worse preoperative PROMIS PF (p = 0.001), PI (p < 0.001), Fatigue (p < 0.001), SS (p < 0.001), and NPS score (p = 0.004). After controlling for confounders, multivariable analysis confirmed increased PROMIS Depression as an independent predictor of worse preoperative PROMIS PF (p = 0.009), MODEMS Expectations (p = 0.025), and NPS score (p = 0.002). Increased PROMIS Anxiety was predictive of worse baseline PROMIS PI (p < 0.001), Fatigue (p < 0.001), and Social Satisfaction (p < 0.001). A previous clinical diagnosis of depression or anxiety was only an independent predictor of worse baseline PROMIS Fatigue (p = 0.002) and was insignificant in all other models.

CONCLUSION

Increasing severity of depression and anxiety correlated with and predicted worse functional status at baseline in hip arthroscopy patients. As compared to clinical diagnosis of anxiety and depression, PROMIS metrics have superior utility in recognizing potentially modifiable mental health concerns that predict worse preoperative status. Ultimately, the study identifies an at-risk population undergoing hip arthroscopy that requires particular attention and potential mental health intervention in the preoperative setting.

LEVEL OF EVIDENCE

III.

Machine Learning-Derived Acetabular Dysplasia and Cam Morphology Are Features of Severe Hip Osteoarthritis: Findings From UK Biobank

The contribution of shape changes to hip osteoarthritis (HOA) remains unclear, as is the extent to which these vary according to HOA severity. In the present study, we used statistical shape modeling (SSM) to evaluate relationships between hip shape and HOA of different severities using UK Biobank DXA images. We performed a cross-sectional study in individuals with left hip dual-energy X-ray absorptiometry (DXA) scans. Statistical shape modeling (SSM) was used to quantify hip shape. Radiographic HOA (rHOA) was classified using osteophyte size and number and joint space narrowing. HOA outcomes ranged in severity from moderate (grade 2) to severe (grade ≥3) rHOA, hospital-diagnosed HOA, and subsequent total hip replacement (THR). Confounder-adjusted logistic regression between the top 10 hip shape modes (HSMs) and OA outcomes was performed. Further models adjusted for alpha angle (AA) and lateral center-edge angle (LCEA), reflecting acetabular dysplasia and cam morphology, respectively. Composite HSM figures were produced combining HSMs associated with separate OA outcomes. A total of 40,311 individuals were included (mean 63.7 years, 47.8% male), of whom 5.7% had grade 2 rHOA, 1.7% grade ≥3 rHOA, 1.3% hospital-diagnosed HOA, and 0.6% underwent THR. Composite HSM figures for grade 2 rHOA revealed femoral neck widening, increased acetabular coverage, and enlarged lesser and greater trochanters. In contrast, grade ≥3 rHOA, hospital-diagnosed HOA, and THR were suggestive of cam morphology and reduced acetabular coverage. Associations between HSMs depicting cam morphology and reduced acetabular coverage and more severe HOA were attenuated by AA and LCEA adjustment, respectively. Relationships between hip shape and HOA differed according to severity. Notably, cam morphology and acetabular dysplasia were features of severe HOA, but unrelated to moderate disease, suggesting possible prognostic utility. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Hyperlipidemia does not influence clinical outcome in arthroscopic treatment of femoroacetabular impingement syndrome

Background

Cholesterol can trigger degenerative processes in the chondrocytes. The internal layer of the hip labral consists of cartilage-specific type II collagen-positive fibrocartilage. The purpose of this study was to compare outcomes after arthroscopy labral repair in FAIS patients with preoperative hyperlipidemia to a control group with no hyperlipidemia.

Methods

Data were prospectively collected and retrospectively reviewed for FAIS patients who had arthroscopy 2019. Patients with hyperlipidemia were 1:1 propensity-score matched to patients without hyperlipidemia. Patient-reported outcomes (HOS-ADL, iHOT-12, mHHS), VAS scores, radiographic measures, performed procedures, complications, and revision surgery were compared and analyzed for both groups.

Results

A total of 41 patients with hyperlipidemia and 41 patients without hyperlipidemia were found using propensity-score matching. When compared to preoperative levels, both groups demonstrated significant improvements in PROs and VAS scores at the final follow-up. Besides, there were no significant differences in preoperative scores and final outcome scores between the groups. Besides, there were no other differences in revision rate and the rate of meeting the PASS and MCID between the study and the control groups.

Conclusion

It was demonstrated in this study that FAIS patients with hyperlipidemia can expect to experience similar good short-term patient-reported outcomes as compared with patients without hyperlipidemia.

Level of evidence

Case-series study; Level of Evidence: Level III.

An Updated Review of Femoroacetabular Impingement Syndrome

Femoroacetabular impingement (FAI) is a chronic hip condition caused by femoral head and acetabular malformations resulting in abnormal contact across the joint. FAI often leads to labral, cartilaginous, and tissue damage that predispose this patient population to early osteoarthritis (OA). There are a variety of factors that increase the risk for FAI including younger age, Caucasian background, familial FAIS morphology, and competing in high-intensity sports during adolescence. Slow-onset, persistent groin pain is the most frequent initial presenting symptom. On physical examination, patients will typically have a positive FADIR test (flexion, adduction, internal rotation), also known as a positive impingement sign. FAI syndrome can be organized into three classifications; cam, pincer, or mixed. This classification refers to the characteristic morphological changes of the bony structures. The primary imaging modality for diagnosing FAI is a plain radiograph of the pelvis, which can be used to measure the alpha angle and the lateral center edge angle used to quantify severity. Conservative treatment is typically considered first-line treatment for mild to moderate FAI syndrome; however, the outcomes following postoperative surgical intervention have demonstrated excellent results. The most common surgical treatment option for FAI is done arthroscopically.

Digital Care Programs for Chronic Hip Pain: A Prospective Longitudinal Cohort Study

Chronic hip pain is a cause of disability worldwide. Digital interventions (DI) may promote access while providing proper management. This single-arm interventional study assesses the clinical outcomes and engagement of a completely remote multimodal DI in patients with chronic hip pain. This home-based DI consisted of exercise (with real-time biofeedback), education, and cognitive-behavioral therapy. Outcomes were calculated between baseline and program end, using latent growth curve analysis. Primary outcome was the Hip Disability and Osteoarthritis Outcome Score (HOOS). Secondary outcomes were pain, intent to undergo surgery, mental health, productivity, patient engagement (exercise sessions frequency), and satisfaction. Treatment response was assessed using a 30% pain change cut-off. A completion rate of 74.2% (396/534), alongside high patient engagement (2.9 exercise sessions/week, SD 1.1) and satisfaction (8.7/10, SD 1.6) were observed. Significant improvements were observed across all HOOS sub-scales (14.7−26.8%, p < 0.05), with 66.8% treatment responders considering pain. Marked improvements were observed in surgery intent (70.1%), mental health (54%), and productivity impairment (60.5%) (all p < 0.001). The high engagement and satisfaction reported after this DI, alongside the clinical outcome improvement, support the potential of remote care in the management of chronic hip conditions.

Platelet-Rich Plasma Is Not Associated With Improved Outcomes Following Hip Femoroacetabular Impingement Surgery: Very Low-Quality Evidence Suggests Hyaluronic Acid and Cell-Based Therapies May Be Beneficial—A Systematic Review of Biological Treatments

Purpose

To examine the efficacy of biologic agents in the treatment of cartilage defects associated with femoroacetabular impingement (FAI).

Methods

PubMed, Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and the Cochrane Database of Systematic Reviews were reviewed by 2 independent reviewers for eligible studies. We included randomized and nonrandomized control trials as well as uncontrolled case series and retrospective studies. Studies were excluded if they included injections of corticosteroids, papers that described technique only, review papers, and those not in the English language. Demographics, treatment type, outcome of treatment, and complications were extracted, whereas risk of bias and study quality were assessed independently using the risk of bias tool (ROB2) and effective public health practice project tool. A narrative synthesis was performed, and standardized mean differences were reported. Certainty of evidence was assessed using the GRADE approach.

Results

Eighteen studies consisting of 1,024 patients met the inclusion criteria. Three studies involved the use of platelet-rich plasma (PRP) as an adjuvant to surgery and were included in the meta-analysis. Three studies administered hyaluronic acid (HA) as a primary treatment. Twelve involved various cell-based methods of chondrocyte stimulation for cartilage defects associated with FAI, but heterogeneity did not allow for pooling. Low-quality evidence indicates PRP is not associated with improved outcomes following surgery (mean difference –1.42, 95% confidence interval –3.95 to 1.11, P = .27). Very-low-quality evidence suggests HA (standardized mean difference 1.15, 95% confidence interval 0.64-1.66, P < .001, Z = 4.39) and cell-based therapies may improve function and pain in patients with FAI.

Conclusions

Low-quality evidence indicates PRP is not associated with improved outcomes following hip FAI surgery, and very-low-quality evidence suggests HA and cell-based therapies may improve outcomes.

Level of Evidence

systematic review of Level I-V studies.

Inconclusive and Contradictory Evidence for Outcomes After Hip Arthroscopy in Patients With Femoroacetabular Impingement and Osteoarthritis of Tönnis Grade 2 or Greater: A Systematic Review

PURPOSE

To investigate whether hip arthroscopy (HA) is effective in patients with femoroacetabular impingement and concomitant hip osteoarthritis (OA) of Tönnis grade 2 or greater.

METHODS

This review was registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO, CRD42020210936). It followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines and included multiple databases: MEDLINE, Embase, Web of Science Core Collection, and Cochrane Library. All studies in English or German from database inception to December 1, 2020, that investigated outcomes of HA in patients with OA of Tönnis grade 2 or greater were considered eligible. The risk of bias was assessed using the MINORS (Methodological Index for Non-randomized Studies) tool. Data heterogeneity was explored using the I² test in a random-effects model.

RESULTS

Eleven studies met the eligibility criteria. The MINORS (Methodological Index for Non-randomized Studies) score averaged 68% (range, 46%-81%). A total of 616 hips, consisting of 247 hips of interest (Tönnis grade 2 or greater) and 369 controls, were included. The weighted estimated follow-up averaged 29.1 months (range, 12-84 months). Data on patient-reported outcome measures (PROMs) could be extracted for 6 of 11 studies, and date on conversion to total hip arthroplasty were available for 8 of 11. Four studies reported an overall improvement in PROMs after HA, and 2 highlighted a failure of improvement in PROMs. Failure of HA with conversion to total hip arthroplasty was observed at a rate of 0% to 9% in 4 studies, as opposed to proportions as high as 35% to 70% in the other 4 studies. There was a high level of heterogeneity, with a calculated I² value of 89%.

CONCLUSIONS

There is currently contradictory and insufficient evidence regarding the efficacy of HA for hips with femoroacetabular impingement and concomitant OA of Tönnis grade 2 or greater. This is in the context of data with low levels of evidence, mainly consisting of retrospective case series (Level IV) with a high risk of bias and high heterogeneity (I² of approximately 90%).

LEVEL OF EVIDENCE

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

Conservative therapy versus arthroscopic surgery of femoroacetabular impingement syndrome (FAI): a systematic review and meta-analysis

Purpose

FAI (femoroacetabular impingement syndrome) is a common cause of hip pain, resulting in a decreased life quality. This study aims to compare the postoperative clinical outcome between arthroscopic surgery (AT) and conservative treatment (CT).

Method

The six studies were selected from PubMed, Embase and OVID database. The data were extracted and analyzed by RevMan5.3. Mean differences and 95% confidence intervals were calculated. RevMan5.3 was used to assess the risk of bias.

Result

Six observational studies were assessed. The methodological quality of the trials indicated five of six studies had a low risk of bias and one article had a high risk of bias. The differences were statistically significant between AT and CT for HOS (follow-up for 6 months), iHOT-33 (follow-up for 6 months) improvement, iHOT-33 (follow-up for 12 months) improvement, iHOT-33 (follow-up for 12 months), EQ-5D-5L index score (follow-up for 12 months) and AT showed higher benefits than CT. Meanwhile no statistically significant were found in iHOT-33 (follow-up for 6 months), EQ-5D-5L index score (follow-up for 6 months), EQ5D-VAS (follow-up for 6 months) and EQ5D-VAS (follow-up for 12 months).

Conclusion

AT and CT both can have clinical effects when facing FAI. In our meta-analysis, hip arthroscopy is statistically superior to conservative treatment in both long-term and short-term effects.

[Results after FAIS surgery-what is the evidence?]

BACKGROUND

The treatment of femoroacetabular impingement syndrome (FAIS) and its sequelae has changed over the past 20 years based on a steadily increasing understanding of the condition and improvements in surgical techniques.

QUESTION

What is the evidence for the treatment of FAIS?

METHODS

Analysis of the available literature, structured review, and discussion of the relevant literature.

RESULTS

The treatment of FAIS has evolved over time through several phases. In the first phase, the clinical picture and its open treatment by surgical hip dislocation were described. Subsequently, the first comparative studies between open, mini-open, and arthroscopic therapy were published. After development of disease-specific patient-reported outcome measurement systems, the concerns of the young, more active patient population could be captured. In recent years, prospective randomized controlled trials comparing conservative versus surgical therapy of FAIS have been published, showing the superiority of surgical treatment and also the need to strengthen evidence-based research especially in the field of conservative treatment of FAIS.

CONCLUSION

The pathomechanism and sequelae of FAIS have been increasingly studied scientifically in recent years. The superiority of a particular surgical technique cannot be demonstrated; the arthroscopic technique has a lower complication rate and a faster convalescence. Clinically important outcome measures are also becoming increasingly established in the therapy of FAIS to capture the clinical relevance for the individual.

Benefits and Harms of Interventions With Surgery Compared to Interventions Without Surgery for Musculoskeletal Conditions: A Systematic Review With Meta-analysis

OBJECTIVE

To estimate the benefits and harms of interventions with and without surgery for musculoskeletal (MSK) conditions.

DESIGN

Intervention systematic review with meta-analysis of randomized controlled trials (RCTs).

LITERATURE SEARCH

MEDLINE, EMBASE, CINAHL, Web of Science, and CENTRAL, all up to January 7, 2021.

STUDY SELECTION CRITERIA

RCTs (English, German, Danish, Swedish, and Norwegian) of interventions with and without surgery conducted in any setting for any non-fracture MSK condition in adults (mean age: 18+ years) evaluating the outcomes on a continuous (benefits) or count (harms) scale. Outcomes were pain, self-reported physical function, quality of life, serious adverse events (SAEs), and death at 1 year.

DATA SYNTHESIS

Random-effects metaanalyses for MSK conditions where there were data from at least 2 trials.

RESULTS

One hundred RCTs (n = 12 645 patients) across 28 different conditions at 9 body sites were included. For 9 out of 13 conditions with data on pain (exceptions include some spine conditions), 11 out of 11 for function, and 9 out of 9 for quality of life, there were no clinically relevant differences (standardized mean difference of 0.50 or above) between interventions with and without surgery. For 13 out of 16 conditions with data on SAEs and 16 out of 16 for death, there were no differences in harms. Only 6 trials were at low risk of bias.

CONCLUSION

The low certainty of evidence does not support recommending surgery over nonsurgical alternatives for most MSK conditions with available RCTs. Further high-quality RCTs may change this conclusion. J Orthop Sports Phys Ther 2022;52(6):312-344. doi:10.2519/jospt.2022.11075.

Do the outcomes of hip arthroscopy for femoroacetabular impingement change over time?

BACKGROUND

The purpose of this study was to search for changes in functional outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement (FAI) between short and medium-term follow-up. Secondary aims included reporting rates of revision surgery and total hip arthroplasty (THA) at medium-term follow-up.

HYPOTHESIS

We hypothesised that patients' functional outcomes would improve between short and medium-term follow-up.

PATIENTS AND METHODS

Consecutive patients undergoing hip arthroscopy with a diagnosis of femoroacetabular impingement with labral tears between February 2013 and June 2015 were included. Twelve item international hip outcome tool (iHOT-12) and EuroQol 5D-5L (EQ-5D) scores were collected preoperatively, at short-term and medium-term follow-up. Short-term scores were recorded at a minimum of one year postoperatively and medium-term scores at a minimum of five years postoperatively. Survivorship was assessed with Kaplan-Meier analysis.

RESULTS

Short-term outcome data (at median follow-up 1.6 year, Interquartile range [IQR] 1-2.5) was available for 70 of 87 patients (80.5%) and medium-term outcome data (at median follow-up of 6.5 years, IQR 6-7.1) was available for 68 patients (78.2%). Median age at the time of surgery was 31 years (IQR 25-37). The median iHOT-12 scores at short and medium-term follow-up were 72 (IQR 48.75-91.25) and 85.8 (IQR 66.7-96.7) respectively (p<0.001). Medium-term survivorship was 91.2%. Survivorship following labral repair was 94.2%, and 81.3% following labral debridement (p=0.09).

DISCUSSION

Patients undergoing hip arthroscopy for FAI reported continued improvement in iHOT-12 scores between short and medium-term follow-up. Medium-term survivorship following FAI surgery may be greater when the labrum is repaired, although comparisons are limited by their differing indications. Conversion to THA was low with just 4 patients (4.6%) undergoing or being listed for THA at final follow-up.

LEVEL OF EVIDENCE

IV, Case series.