Predictors of Clinical Outcomes After Hip Arthroscopy: A Prospective Analysis of 1038 Patients With 2-Year Follow-up

Ten-Year Outcomes in Patients Aged 40 Years and Older After Primary Arthroscopic Treatment of Femoroacetabular Impingement With Labral Repair

BACKGROUND

Arthroscopic labral repair has been shown to result in favorable short- and midterm outcomes; however, the durability of outcomes specifically in older patients remains underreported.

PURPOSE

To (1) report prospectively collected hip preservation rates and patient-reported outcome measures (PROMs) at a minimum 10-year follow-up in patients aged ≥40 years after primary hip arthroscopy with labral repair and (2) perform a matched analysis comparing patients aged ≥40 years with patients aged <40 years.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients who underwent primary hip arthroscopy between February 2008 and December 2011. Patients aged ≥40 years who underwent labral repair were included. Preoperative and minimum 10-year follow-up scores were collected for multiple PROMs. Propensity score matching was utilized to compare these patients with a cohort of patients <40 years.

RESULTS

Of the 113 hips eligible, 91 hips (80.5%) on 85 patients (6 bilateral) had a minimum 10-year follow-up. There were 58 women (68%) and 27 men (32%) with a mean age and body mass index of 47.8 years and 25.8, respectively. The hip preservation rate for patients aged ≥40 years was 78%, with 20 patients requiring arthroplasty during the study period. There was significant improvement in all PROMs from baseline to minimum 10-year follow-up with high rates of achieving the minimal clinically important difference and Patient Acceptable Symptom State clinical outcome thresholds. In total, 69 patients aged ≥40 years were propensity matched to 107 patients <40 years. Patients ≥40 tended to have a lower hip preservation rate (81.2% vs 91.6%; P = .06), while patients in the younger cohort had significantly higher rates of secondary hip arthroscopy (14% vs 3%; P = .02). Improvement in PROMs was comparable between the groups.

CONCLUSION

Patients ≥40 years who underwent primary hip arthroscopy with labral repair demonstrated a hip preservation rate of 78%, significant and durable improvement in PROMs, and high rates of satisfaction at a minimum 10-year follow-up. Matched analysis with patients <40 years revealed comparable improvement in patient-reported outcomes between the 2 groups, with a tendency to a higher level of arthroplasty in patients ≥40 years.

Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: 24-Month Results From a Randomized Controlled Trial

BACKGROUND

The indications for hip arthroscopy in patients aged ≥40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty.

PURPOSE

To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged ≥40 years with limited radiographic osteoarthritis.

STUDY DESIGN

Randomized controlled trial; Level of evidence, 1.

METHODS

This single-surgeon, parallel randomized controlled trial included patients aged ≥40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing ≥14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses.

RESULTS

A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion.

CONCLUSION

In patients ≥40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age ≥40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair.

REGISTRATION

NCT03909178 (ClinicalTrials.gov identifier).

Primary Total Hip Arthroplasty Outcomes for Labral Tears are Comparable to Advanced Osteoarthritis

BACKGROUND

There is a paucity of evidence on outcomes following total hip arthroplasty (THA) in patients who have symptomatic degenerative labral tears and mild to moderate osteoarthritis (OA). The purpose of this study was to determine if outcomes of primary THA in the setting of painful, symptomatic labral tear and mild to moderate arthritic changes were comparable to outcomes of primary THA performed for severe arthritic changes. Primary outcomes were patient-reported outcome (PRO) scores. Secondary outcomes included length of stay and perioperative complications.

METHODS

This was a retrospective investigation of all THAs between January 2018 and July 2022. There were 111 patients who had THA due to failure of nonoperative treatment of a degenerative labral tear without advanced arthritic changes (mild to moderate OA cohort, Kellgren-Lawrence Grades 1 to 3). These patients were matched to 111 patients who underwent THA for advanced OA (AOA cohort, Kellgren-Lawrence Grade 4). PROs included the Western Ontario McMaster Universities Arthritis Index (WOMAC). The average age for the labral tear cohort was 59 years, with 50.6% women, compared to 70 years (P < 0.001), and 49.4% women (P = 0.93) in the AOA cohort.

RESULTS

There were no differences in preoperative PROs, complications, or length of stay between groups. When looking at postoperative PROs between cohorts, the labral tear cohort had less improvement in WOMAC-Stiffness (24.3 versus 34.0, P = 0.005) and WOMAC-Functional limitation (26.3 versus 36.0, P = 0.005) at 12 months and greater improvement in WOMAC-Pain at 12 months (38.3 versus 34.7, P = 0.04). The Short Form 12-Physical function scores were significantly higher among the labral tear cohort compared to the AOA cohort at 12 months (48.5 versus 47.8, P < 0.001). The Short Form 12-Mental scores were significantly higher in the AOA cohort compared to the labral tear cohort at 3 months (47.1 versus 47.4, P = 0.02) and 12 months (46.7 versus 47.6, P < 0.001). In the multivariate analysis, the change in WOMAC-Pain at 12 months was significantly better for labral tear patients (odds ratio 7.5, P = 0.008, confidence interval 6.85 to 8.14).

CONCLUSIONS

Our study showed that patients who have symptomatic degenerative labral tears with mild to moderate arthritic changes have comparable outcomes to patients who have AOA following primary THA. Given suboptimal outcomes with hip arthroscopy for labral tear in the setting of early arthritis, primary THA can be a reasonable treatment modality for patients failing nonoperative treatments.

Primary Hip Arthroscopy Is Associated With Earlier Achievement of Substantial Clinical Benefit Compared With Revision Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To compare time to achievement of clinically significant outcomes (CSOs) between patients undergoing primary and revision hip arthroscopy (HA) for femoroacetabular impingement syndrome.

METHODS

Patients undergoing primary and revision HA for femoroacetabular impingement syndrome with complete 6-month, 1-year, and 2-year Hip Outcome Score-Activities of Daily Living (HOS-ADL) and Sport Subscale (HOS-SSS) were identified. Revision patients were propensity matched 1:4 to primary patients with HA, controlling for age, sex, and body mass index (BMI). Time to achievement of minimal clinically important difference and substantial clinical benefit (SCB) were compared alongside cumulative CSO achievement at 6, 12, and 24 months. Hazard ratios (HRs) for predictors of earlier CSO achievement were identified with multivariate Cox regressions.

RESULTS

Fifty patients with revision HA were propensity-matched to 200 patients with primary HA of similar age, sex, and BMI. Patients with primary HA demonstrated a greater prevalence of regular preoperative physical activity (87% vs 59%, P < .001). Patients with primary HA showed significantly greater SCB achievement for HOS-ADL at 6, 12, and 24 months (P < .001) and significantly greater SCB achievement for HOS-SSS at 12 and 24 months (P ≤ .001) compared with patients with revision HA. Patients with primary HA achieved SCB for HOS-ADL (P < .001) and HOS-SSS (P = .015) quicker than patients with revision HA. Predictors of earlier CSO achievement included preoperative PRO score (HR 0.98-1.02, P ≤ 0.007), lower BMI (HR 0.97, P = .038), presence of physical activity (HR 1.51, P = .038), and absence of revision status (HR 0.52-0.56, P ≤ .019).

CONCLUSIONS

Patients with primary HA showed a quicker time to SCB achievement for HOS-ADL and HOS-SSS compared with patients with revision HA. Preoperative PRO score, lower BMI, regular physical activity, and primary HA status predicted earlier CSO achievement.

LEVEL OF EVIDENCE

Level III, retrospective comparative series.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

Predictors of Clinical Outcomes After Hip Arthroscopy: 10-Year Follow-up Analysis of 1038 Patients

BACKGROUND

Although hip arthroscopy has been shown to have beneficial outcomes, there is a paucity of literature examining predictive factors of 10-year clinical outcomes.

PURPOSE

(1) To identify predictive factors of 10-year outcomes of hip arthroscopy and (2) to compare these factors with those found in 2-year and 5-year studies.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had a minimum 10-year follow-up on 2 patient-reported outcome measures: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Exclusion criteria included previous ipsilateral hip conditions. Using bivariate and multivariate analyses, that authors analyzed the effects of 37 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.

RESULTS

Of the 883 patients who met the inclusion criteria, 734 (83.1%) had follow-up data. The mean follow-up time was 124.4 months (range, 120.0-153.1 months). Six variables were significant predictors of NAHS in both multivariate and bivariate analyses: revision status, body mass index (BMI), duration of symptoms, preoperative NAHS, age at onset of symptoms, and need for acetabular microfracture. Positive predictors of 10-year survivorship included acute injury and gluteus medius repair, while negative predictors included revision arthroscopy, Tönnis grade, acetabular inclination, iliopsoas fractional lengthening, and notchplasty.

CONCLUSION

Multiple predictive factors including age, BMI, revision status, and preoperative outcome scores were identified for long-term survivorship and functional outcomes. These may prove useful to clinicians in refining indications and guiding patients on expected outcomes of hip arthroscopy.

Endoscopic Hip Abductor Tendon Repair Results in Successful Outcomes With 5- to 10-Year Follow-Up

PURPOSE

To report the outcomes of endoscopic repair in a consecutive series of patients with follow-up ranging from 5 to 10 years.

METHODS

Sixty-five consecutive hips in 63 patients (2 bilateral) undergoing endoscopic abductor tendon repair with minimum 5-year follow-up were assessed with the modified Harris Hip Score. The minimal clinically important difference (MCID) was determined as one-half the standard deviation of the amount of improvement.

RESULTS

The mean age was 56.6 years (standard deviation [SD], 11.3 years), with 58 female and 5 male patients. Follow-up was obtained on 64 hips (98.5%) at a mean of 85 months (SD, 15.7 months). There were 33 full-thickness and 32 partial-thickness tears, with 40 gluteus medius tears, 23 medius and minimus tears, and 2 isolated minimus tears. Concomitant arthroscopy of the hip joint was performed in 50 patients (52 hips), including 15 with correction of femoroacetabular impingement. The mean modified Harris Hip Score was 48.4 (SD, 15.7) preoperatively and 83.4 (SD, 15.9) postoperatively, reflecting a mean improvement of 34.9 (95% confidence interval, 34.9 ± 4.3), with 92.2% of patients achieving the MCID of 8.7. There were no complications. Three patients underwent further surgery: One underwent total hip replacement at 11 months after abductor repair, one underwent repeated arthroscopy for joint debridement at 12 months after repair, and one underwent revision abductor repair at 6 years postoperatively.

CONCLUSIONS

Collectively, with 5- to 10-year follow-up, patients undergoing endoscopic abductor tendon repair can respond exceptionally well, with 92.2% achieving the MCID, even among a heterogeneous group of partial- and full-thickness tears with single- and 2-tendon involvement undergoing single- and double-row repair.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Patients With Lumbar Pathology or Ipsilateral Knee Pathology Improve After Hip Arthroscopy, but Outcomes Are Not as Good as in Patients With Femoroacetabular Impingement Syndrome Without Concomitant Pathology

From the lumbar spine to foot, the joints of the lower extremity are all intimately connected. Their movements are synchronized in a complex biomechanical dance. Pain in one joint tends to affect the joint above and joint below. Understanding the influence of adjacent-joint disease on the hip can help us better counsel patients undergoing hip surgery. Low-back pathology has been shown to negatively influence outcomes after hip arthroscopy. Ipsilateral knee pain appears to do the same. Patients with femoroacetabular impingement syndrome with ipsilateral knee pain should be counseled that their outcomes may not be quite as good as those without knee pain, but they should be able to expect meaningful improvement of their symptoms, both at the hip and at the knee after hip arthroscopy.

Defining the Percent Thresholds for Achieving the Maximum Outcome Improvement of the Modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Sports Subscale, the Visual Analog Scale for Pain, and the International Hip Outcome Tool-12 in Revision Hip Arthroscopy at Minimum 2-Year Follow-Up

PURPOSE

To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following revision hip arthroscopy, and to identify predictors for achieving the MOI.

METHODS

An anchor question was provided to patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included for the final analysis if they answered the anchor question and had minimum 2-year follow-up. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. A P-value of < .05 was considered significant.

RESULTS

In total, 318 patients underwent revision hip arthroscopy. Of those patients, 292 (91.8%) had minimum 2-year follow-up. Of this cohort, 68 answered the anchor question, with 49 (72.1%) female and 19 (27.9%) male patients. The mean age, and body mass index time were 32.9 ± 13 years and 25.4 ± 5.1, respectively. It was determined that 42.1%, 50%, 48.1%, 50%, and 50% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, HOS-SS, VAS for pain, and the iHOT-12, respectively. The presence of unaddressed subspine impingement was a significant predictor for achieving the MOI threshold for the VAS (odds ratio 1.40; 95% confidence interval 1.00-1.95; P = 0.0273).

CONCLUSIONS

Following revision hip arthroscopy, the percent thresholds for achieving the MOI at a minimum 2-year follow-up for the mHHS, NAHS, HOS-SS, VAS for pain, and iHOT-12 were 42.1%, 50%, 48.1%, 50%, and 50.9%, respectively. Addressing residual subspine impingement was identified as significant positive predictor for achieving the MOI.

LEVEL OF EVIDENCE

Level IV, case-series.

Five-Year Outcomes of Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome Among Female Patients: Higher Body Mass Index Is Associated With Reduced Clinically Significant Outcomes

PURPOSE

To evaluate the impact of age, body mass index (BMI), and symptom duration on 5-year clinical outcomes among females following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

We conducted a retrospective review of a prospectively collected database of hip arthroscopy patients with a minimum 5-year follow-up. Patients were stratified by age (<30, 30-45, ≥45 years), BMI (<25.0, 25.0-29.9, ≥30.0), and preoperative symptom duration (<1 vs ≥1 year). Patient-reported outcomes were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Pre- to postoperative improvement in mHHS and NAHS was compared between groups using the Mann-Whitney U test or Kruskal-Wallis test. Hip survivorship rates and minimum clinically important difference (MCID) achievement rates were compared with Fisher exact test. Predictors of outcomes were identified using multivariable linear and logistic regression. P values <.05 were considered significant.

RESULTS

In total, 103 patients were included in the analysis with a mean age of 42.0 ± 12.6 years (range, 16-75) and mean BMI of 24.9 ± 4.8 (range, 17.2-38.9). Most patients had symptoms of duration ≥1 year (60.2%). Six patients (5.8%) had arthroscopic revisions, and 2 patients (1.9%) converted to total hip arthroplasty by 5-year follow-up. Patients with BMI ≥30.0 had significantly lower postoperative mHHS (P = .03) and NAHS (P = .04) than those with BMI <25.0. Higher BMI was associated with reduced improvement in mHHS (β = -1.14, P = .02) and NAHS (β = -1.34, P < .001) and lower odds of achieving the mHHS MCID (odds ratio [OR] = 0.82, P = .02) and NAHS MCID (OR = 0.88, P = .04). Older age was predictive of reduced improvement in NAHS (β = -0.31, P = .046). Symptom duration ≥1 year was predictive of higher odds of achieving the NAHS MCID (OR = 3.98, P = .02).

CONCLUSIONS

Female patients across a wide range of ages, BMIs, and symptom durations experience satisfactory 5-year outcomes following primary hip arthroscopy, but higher BMI is associated with reduced improvement in patient-reported outcomes.

LEVEL OF EVIDENCE

Level III, retrospective comparative prognostic trial.

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.

Recovery After Hip Arthroscopy in Patients With Combined Femoroacetabular Impingement and Labral Tears Compared With Isolated Pathology

Background

Outcomes for patients with femoroacetabular impingement (FAI) treated with hip arthroscopy can differ depending on whether there is underlying intra-articular pathology.

Purpose

To evaluate the outcomes of patients after undergoing hip arthroscopy depending on their underlying pathology (isolated FAI, isolated labral tear, or combined FAI and a labral tear) using the 12-Item International Hip Outcome Tool (iHOT-12).

Study Design

Cohort study; Level of evidence, 3.

Methods

A total of 75 patients diagnosed with FAI with or without labral tears and isolated labral tears who underwent hip arthroscopy performed by the same surgeon at a single institution from January 2014 to December 2019 were included in this study. All patients had at least 2 years of follow-up data. Patients were divided into 3 groups as follows: patients with FAI and an intact labrum; patients with an isolated labral tear; and patients with combined FAI and a labral tear. The iHOT-12 scores at 1.5, 3, 6, 12, 18, and >24 months postoperatively were compared and analyzed. Outcome scores were also evaluated in terms of the substantial clinical benefit (SCB) and the patient-acceptable symptomatic state (PASS).

Results

Of 75 patients who underwent hip arthroscopy, 14 had FAI, 23 had labral tears, and 38 had both. All groups showed significant improvements on the iHOT-12 from preoperative to the final follow-up (FAI, from 37.64 ± 3.77 to 93.64 ± 1.50; labral tear, from 33.70 ± 3.55 to 93 ± 1.24; combined, from 28.55 ± 3.15 to 93.03 ± 0.88) (P < .001 for all). However, compared with other groups, the patients with FAI and a labral tear had lower scores at 1.5, 3, 6, and 12 months postoperatively (P < .001), highlighting a slower rate of recovery. For all groups, recovery to normal function according to the SCB was 100% at 12 months, and satisfaction according to the PASS was 100% at 18 months postoperatively.

Conclusion

The final iHOT-12 scores were similar at 18 months regardless of the pathology treated; however, patients with FAI and a labral tear took longer to reach their plateau.

High survivorship and excellent 5-year outcomes in patients older than 40 years undergoing arthroscopy for femoroacetabular impingement

PURPOSE

To assess 5-year clinical outcome, in adults > 40 years of age, following hip arthroscopy for femoroacetabular impingement compared to a younger, matched, control group.

METHODS

All primary arthroscopies for FAI between 2009 and 2016 were considered (n = 1762). Hips presenting with Tönnis > 1, lateral centre edge angle < 25°, or prior hip surgery were excluded. Younger (< 40 years) and older hips (> 40 years) were matched for gender, Tönnis grade, capsular repair and radiological parameters. Survival (avoidance of total hip replacement {THR}) was compared between the groups. Patient reported outcome measures (PROMs) were also completed at baseline and 5 years to assess changes in functional capacity. Additionally, hip range of motion (ROM) was assessed at baseline and review. The minimal clinically important difference (MCID) was determined and compared between groups.

RESULTS

Ninety-seven older hips were matched to 97 younger controls (78% male in both groups). The average age of the older group at the time of surgery was 48.0 ± 5.7 years, compared to 26.7 ± 6.0. Six (6.2%) of the older hips and 1 (1%) of younger hips converted to THR (p = 0.043, effect size = 0.74, large). There were statistically significant improvements in all PROMs. At follow-up, there were no differences in PROMs between groups; significant improvements in hip ROM were also observed with no difference in ROM between groups at either time point. Similar achievement of MCIDs was observed in both groups.

CONCLUSIONS

Older patients experience a high survivorship rate at 5 years, although this may be lower than younger patients. Where THR is avoided, large clinically significant improvements in pain and function are observed.

LEVEL OF EVIDENCE

Level IV.

Patients With Low-Grade Lumbosacral Transitional Vertebrae Demonstrate No Difference in Achievement of Clinical Thresholds After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

To compare clinical outcomes at 2 years following primary hip arthroscopy (HA) for femoroacetabular impingement syndrome (FAIS) between patients with and without low-grade lumbosacral transitional vertebra (LSTV).

METHODS

We performed a retrospective matched-cohort analysis of patients who underwent primary HA for FAIS from 2011 to 2018 with minimum 2-year follow-up. LSTV was graded on preoperative radiographs using the Castellvi classification. Patients with grades I and II LSTV were matched 1:1 with controls on age, sex, and body mass index. Radiographic markers of FAIS morphology were measured. Pre- to postoperative improvement in the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) as well as 2-year achievement rates for the minimum clinically-important difference, substantial clinical benefit, and patient acceptable symptom state were compared between patients with versus without LSTV. The Wilcoxon signed-rank test was used for intergroup mean comparisons and the Cochran-Mantel-Haenszel test for categorical variables.

RESULTS

In total, 58 patients with LSTV were matched to 58 controls. Among LSTV patients, 48 were Castellvi type 1 (82.8%) and 32 (55.2%) had bilateral findings. No significant differences were found between groups with respect to radiographic markers of FAIS, including alpha angle (P = .88), lateral center edge angle (P = .42), or crossover sign (P = .71). Although patients with LSTV had greater improvement in NAHS at 2-year follow-up compared with control patients (P = .04), there were no significant differences in modified Harris Hip Score improvement (P = .31) or achievement of the minimum clinically-important difference (P = .73), substantial clinical benefit (P = .61), or patient acceptable symptom state (P = .16).

CONCLUSIONS

Patients with low-grade LSTV had greater 2-year improvement in NAHS than controls, whereas no significant differences were observed in achievement of clinical thresholds at 2-year follow-up. There were no differences between groups with respect to any measured radiographic markers of FAIS morphology. Importantly, the findings of this study are underpowered and should be viewed with caution in the greater context of the LSTV literature.

LEVEL OF EVIDENCE

III; retrospective comparative study.

Hip Arthroscopy for Femoroacetabular Impingement Syndrome Shows Good Outcomes and Low Revision Rates, With Young Age and Low Postoperative Pain Score Predicting Excellent 5-Year Outcomes

PURPOSE

To evaluate the clinical outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and their predictors at a minimum 5 years' follow-up.

METHODS

We retrospectively analyzed patients with FAIS after first-time unilateral hip arthroscopy between January 2010 and July 2016. Patient-reported outcomes (PROs) included the validated modified Harries Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). We included patients with Tönnis grade 0 or 1 and reported PROs, and excluded patients with previous hip diseases or bilateral symptoms. Bivariate and multivariate analyses were used for data analysis.

RESULTS

We included 159 patients with a mean follow-up of 6.4 years, aged 36.18 ± 8.61 years, 41.5% female, and a mean body mass index of 23.61 ± 3.45. The mean postoperative mHHS was 88.82 ± 11.60, and the mean Pain VAS was 1.93 ± 1.89, significantly better than before surgery (P < .001). Postoperative alpha angle (P = .003) and lateral center edge angle (P < .001) were significantly decreased. Most patients (83.7%) achieved clinically important improvement based on patient-acceptable symptom state and minimal clinically important difference (MCID). The overall revision surgery rate was 2.5%. There were no conversions to total hip arthroplasty. Bivariate analysis indicated that age (P < .001), preoperative mHHS (P = .002), and postoperative Pain VAS (P <.001) correlated with postoperative mHHS at a minimum 5 years' follow-up. Multivariate regression analysis of MCID showed that age (P <.001), preoperative PROs (P < .01 for both), and postoperative Pain VAS (P < .001) were significant outcome predictors.

CONCLUSION

Patients with FAIS after first-time unilateral hip arthroscopy showed significant improvement in PROs at mid-term follow-up, with a low revision surgery rate. Young patients and those with low postoperative Pain VAS showed excellent outcomes at a minimum 5 years' follow-up.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Hip arthroscopy for femoroacetabular impingement is associated with significant improvement in early patient reported outcomes: analysis of 4963 cases from the UK non-arthroplasty registry (NAHR) dataset

PURPOSE

Results from recent randomised controlled trials demonstrate the superiority of surgery over physiotherapy in patients with femoroacetabular impingement (FAI) of the hip in early follow-up. However, there is paucity of evidence regarding which factors influence outcomes of FAI surgery, particularly notable is the lack of information on the effect of impingement subtype (cam or pincer or mixed) on patient reported outcomes measures (PROMs). This study aims to evaluate the early outcomes of hip arthroscopy for FAI, and their determinants.

METHODS

This is a retrospective analysis of prospectively collected data from the UK Non-Arthroplasty Hip Registry (NAHR) of patients undergoing arthroscopic intervention for FAI between 2012 and 2019. The null hypothesis was that there is no difference in PROMs, based on morphological subtype of FAI treated or patient characteristics, at each follow-up timepoint. The outcome measures used for the study were the iHOT-12 score and the EQ5D Index and VAS 6- and 12-month follow-up.

RESULTS

A cohort of 4963 patients who underwent arthroscopic treatment of FAI were identified on the NAHR database. For all FAI pathology groups, there was significant improvement from pre-operative PROMs when compared to those at 6 and 12 months. Overall, two-thirds of patients achieved the minimum clinically important difference (MCID), and almost half achieved substantial clinical benefit (SCB) for iHOT-12 by 12 months. Pre-operatively, and at 12-month follow-up, iHOT-12 scores were significantly poorer in the pincer group compared to the cam and mixed pathology groups (p < 0.01). Multivariable analysis revealed PROMS improvement in the setting of a higher-grade cartilage lesion.

CONCLUSION

This registry study demonstrates that hip arthroscopy is an effective surgical treatment for patients with symptomatic FAI and results in a statistically significant improvement in PROMs which are maintained through 12 months follow-up.

LEVEL OF EVIDENCE

III.

Minimum 10-year Survivorship and Clinical Outcomes Following Primary Hip Arthroscopy with Acetabular Microfracture

PURPOSE

To report minimum 10-year follow-up survivorship, defined as non-conversion to total hip arthroplasty (THA), and patient-reported outcome scores (PROS) after primary hip arthroscopy with acetabular microfracture in the setting of femoroacetabular impingement syndrome (FAIS) and acetabular chondral lesions, respectively.

METHODS

Data were prospectively collected and retrospectively analyzed on all patients who underwent a primary hip arthroscopy and received an acetabular microfracture between June 2009 and January 2011. Patients with a minimum 10-year follow-up for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and the visual analog scale (VAS) for pain were included. If available, the minimum 10-year follow-up for the Hip Outcome Score-Sport-Specific Subscale was reported. The demographics, intraoperative findings, surgical procedures, PROS, rate of achieving the minimal clinical important difference (MCID), and secondary surgeries were analyzed and reported.

RESULTS

Twenty-two hips (20 patients) were included in the study, and the mean follow-up time was 124.5 ± 2.2 months. There were 17 hips (77.3%) from males and 5 hips (22.7%) from females. The average patient age at the time of surgery was 42.3 years ± 9.6. All patients on average experienced statistically significant improvement (P < .05) between preoperative and minimum 10-year follow-up scores for all PROs. In total, 77.3% of the patients did not require conversion to THA. Additionally, 83.3% of the patients achieved the MCID for the mHHS, NAHS, and VAS for pain.

CONCLUSION

At a minimum 10-year follow-up, survivorship of 77.3% was reported for patients who underwent primary hip arthroscopy with acetabular microfracture for the treatment of FAIS and focal/full-thickness acetabular cartilage lesions. Further, in the patients that did not require THA conversion, significant improvement in all PROS was demonstrated.

LEVEL OF EVIDENCE

IV, case-series study.

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

PURPOSE

To compare minimum 2-year postoperative patient-reported outcome (PRO) scores and return to sport between competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome with interportal capsulotomy repair and competitive athletes with an unrepaired interportal capsulotomy.

METHODS

Data on all consecutive competitive athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between February 2012 and December 2018 were collected. Athletes were divided into 2 groups: those who underwent repair and those without repair. Athletes were considered eligible if they participated in sports within 1 year prior to surgery. Patients were eligible if the return-to-sport status and the following preoperative and minimum 2-year postoperative PROs were available: modified Harris Hip Score, Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and visual analog scale (VAS) score for pain. Patients were excluded if they underwent prior hip surgery, had Workers' Compensation, were unwilling to consent, had a Tönnis grade greater than 1, or had a previous hip condition. The percentages of patients achieving the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold were recorded. Athletes who underwent interportal capsulotomy repair were propensity score matched in a ratio of 2:1 to athletes without interportal capsulotomy repair according to age, sex, body mass index, sport level, and acetabular labrum articular disruption grade.

RESULTS

Forty-nine athletes (53 hips) without repair with an average follow-up time of 36.5 ± 10.2 months and age of 32.1 ± 13.3 years were matched to 79 athletes (84 hips) with repair with an average follow-up time of 41.3 ± 9.4 months and age of 30.1 ± 12.1 years. Athletes in the repaired group showed significantly greater improvements in the NAHS, HOS-SSS, and VAS score and significantly higher rates of achievement of the MCID for the HOS-SSS compared with athletes in the unrepaired group.

CONCLUSIONS

Competitive athletes who underwent primary hip arthroscopy with interportal capsulotomy repair showed a significantly greater magnitude of improvement in PRO scores (NAHS, HOS-SSS, and VAS score) and rates of achieving the MCID (HOS-SSS) compared with a propensity score-matched control group of competitive athletes with an unrepaired interportal capsulotomy.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Elite Female Athletes Demonstrate a Comparable Improvement in Midterm Patient-Reported Outcome Scores and Rate of Return to Sport Compared With Elite Male Athletes After Hip Arthroscopic Surgery: A Sex-Based Comparison in Professional and Collegiate Athletes

BACKGROUND

Few studies have compared outcomes, return to sport (RTS), and continuation of sport (CTS) after primary hip arthroscopic surgery between matched groups of male and female athletes with a minimum 5-year follow-up.

PURPOSE

(1) To report minimum 5-year patient-reported outcome (PRO) scores as well as RTS and CTS rates for elite female athletes undergoing hip arthroscopic surgery for femoroacetabular impingement syndrome (FAIS) and (2) to compare clinical results with those of a matched control group of elite male athletes.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for elite (collegiate or professional) female athletes who underwent primary hip arthroscopic surgery for FAIS between March 2009 and March 2016. Inclusion criteria were preoperative and minimum 5-year scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous ipsilateral hip surgery/conditions, and those unwilling to participate. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) were recorded in addition to RTS. CTS was also recorded and defined as athletes reporting continued sport activity at a minimum 5-year follow-up after initially reporting returning to sport. Elite female athletes were propensity matched in a 1:1 ratio to elite male athletes for comparison.

RESULTS

A total of 81 hips in elite female athletes that underwent primary hip arthroscopic surgery met the inclusion criteria, and follow-up was available for 65 hips (80.2%) at a mean of 67.6 ± 6.5 months, with a mean age of 24.3 ± 6.8 years. Female athletes demonstrated significant improvements in all recorded PRO scores; achieved the MCID, PASS, and MOIST at high rates; returned to sport at a rate of 80.4%; and continued sport at a rate of 97.1%. Female athletes demonstrated lower preoperative PRO scores compared with male athletes, but postoperative PRO scores; improvements in scores; rates of achieving the MCID, PASS, MOIST; and RTS and CTS rates were similar between female and male athletes.

CONCLUSION

Elite female athletes undergoing primary hip arthroscopic surgery for FAIS demonstrated favorable PRO scores and high RTS and CTS rates at a minimum 5-year follow-up. These results were comparable with those of a propensity-matched control group of elite male athletes.

Relationship of Average Outcomes Scores and Change in Status Requires Further Interpretation Between 1 and 2 Years Following Hip Arthroscopy

BACKGROUND

Previous studies have demonstrated a clinically impactful change in patients between 1 and 2 years after hip arthroscopy. Assessment of differences in patient-specific factors between patients who remain the same and those who change (ie, either improve or decline) could provide valuable outcome information for orthopaedic surgeons treating those patients.

PURPOSE

To identify patients who experienced change in functional status between 1 and 2 years after hip arthroscopy for femoroacetabular impingement syndrome and assess differences in patient-specific factors between those who improved, remained the same, or declined in functional status.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Prospectively collected data for patients who underwent hip arthroscopy at 1 of 7 centers were analyzed retrospectively at 1 year and 2 years postoperatively. Patients were categorized as "improved,""remained the same," or "declined" between 1- and 2-year follow-up based on the 12-item International Hip Outcome Tool (iHOT-12) minimal clinically important difference (MCID) value. A 1-way analysis of variance was used to assess differences in iHOT-12 scores, age, body mass index (BMI), alpha angle, and center-edge angle (CEA) between groups. Chi-square analyses were used to assess differences in the proportions of male and female patients in the outcome groups.

RESULTS

The study included 753 patients (515 women and 238 men), whose mean ± SD age was 34.7 ± 12 years. Average 1-year (±1 month) and 2-year (±2 months) iHOT-12 scores for all patients were 73.7 and 74.9, respectively. Based on the calculated MCID of ±11.5 points, 162 (21.5%) patients improved, 451 (59.9%) remained the same, and 140 (18.6%) declined in status between 1- and 2-year follow-up. Those who improved between 1 and 2 years had lower 1-year iHOT-12 scores (P < .0005). We found no difference in age, BMI, alpha angle, CEA, or sex between groups (P > .05).

CONCLUSION

Between 1- and 2-year follow-up assessments, 21.5% of patients improved and 18.6% declined in self-reported functional status. Those with iHOT-12 scores indicating abnormal function at 1 year improved beyond the MCID at 2 years follow-up. Thus, any decisions about the failure or success of arthroscopic hip procedures should not be made until at least the 2-year follow-up. Failing to thrive at 1-year follow-up may not accurately predict outcomes at year 2 or beyond. This could potentially decrease the perceived need for revision surgery in patients who do not thrive before 2-year follow-up.

Determining Clinically Meaningful Thresholds for the Hip Outcome Score Sport-Specific Subscale in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement Syndrome

BACKGROUND

The minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), substantial clinical benefit (SCB), and maximum outcome improvement (MOI) satisfaction threshold for the Hip Outcome Score Sport-Specific Subscale (HOS-SSS) have not been established in athletes undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

PURPOSE

To determine threshold MCID, PASS, SCB, and MOI satisfaction threshold values for the HOS-SSS in athletes undergoing hip arthroscopy for FAIS at minimum 2-year follow-up.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Anchor questions were administered to recreational, organized amateur, high school, college, and professional athletes who underwent primary hip arthroscopy for FAIS between May 2015 and March 2019. Patients were included if they were younger than 50 years, answered the anchor questions, and had preoperative and minimum 2-year follow-up for the HOS-SSS, modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle <18°), and previous ipsilateral hip surgery or conditions. Receiver operating characteristic (ROC) analysis was used to determine PASS, SCB, and MOI satisfaction for the HOS-SSS. Two distribution methods were used to calculate MCID for HOS-SSS.

RESULTS

A total of 225 athletes who underwent primary hip arthroscopy met the inclusion criteria. Of those athletes, 200 (88.9%) who had minimum 2-year follow-up and information regarding return to sport (RTS) were included. The cohort included 124 (62.0%) women and 76 (38.0%) men with a mean ± standard deviation age of 29.4 ± 10.4 years, body mass index of 25.6 ± 5.4, and follow-up of 29.5 ± 5.1 months. Athletes experienced significant improvements in HOS-SSS, mHHS, NAHS, and VAS from preoperative to latest postoperative follow-up (P < .001), and mean satisfaction was 8.2. The RTS rate was 83.7%. ROC analysis determined that the PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID (baseline/change score methods) for the HOS-SSS were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively, with athletes achieving thresholds at high rates (80.0%, 80.5%, 45.0%, 54.0%, and 79.5%, respectively).

CONCLUSION

This study identified values for the HOS-SSS that can be used to define clinically meaningful outcomes in athletes after primary hip arthroscopy for FAIS. The PASS, MOI satisfaction threshold, SCB absolute score, SCB change score, and MCID for the HOS-SSS at minimum 2-year follow-up in athletes after primary hip arthroscopy were 77.0, 44.6%, 92.7, 30.6, and 10.6, respectively.

Athletes Undergoing Concomitant Hip Arthroscopy and Periacetabular Osteotomy Demonstrate Greater Than 80% Return-to-Sport Rate at 2-Year Minimum Follow-Up

PURPOSE

To report minimum 2-year follow-up patient-reported outcomes and return-to-sport (RTS) rates in athletes undergoing concomitant hip arthroscopy and periacetabular osteotomy (PAO) to treat acetabular dysplasia and intra-articular pathologies such as cam deformity and labral tears.

METHODS

We reviewed the data of consecutive athletes undergoing concomitant primary hip arthroscopy and PAO for acetabular dysplasia and cam deformity from November 2010 to December 2018. Patients were included in the study if they had the following preoperative and minimum 2-year postoperative scores: modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS). The percentage of patients who achieved the minimal clinically important difference was recorded, in addition to RTS status.

RESULTS

A total of 29 athletes (29 hips) were included, with a mean follow-up time of 34.1 ± 7.9 months, mean age of 26.0 ± 8.7 years, and mean body mass index of 23.7 ± 3.4. These athletes showed significant improvements in the mHHS, NAHS, and HOS-SSS from baseline to latest follow-up (P < .001). The minimal clinically important difference was achieved at high rates for the mHHS (82.8%), NAHS (86.2%), and HOS-SSS (79.3%). Athletes who attempted to RTS successfully returned at a rate of 81.8%.

CONCLUSIONS

Athletes undergoing concomitant hip arthroscopy and PAO showed significant improvements in patient-reported outcomes at minimum 2-year follow-up and had an RTS rate of 81.8%.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Females and Males Achieved Comparable Outcomes and Clinical Benefits Following Primary Hip Arthroscopy with Labral Repair, but Age Affected Outcomes and Conversion to Total Hip Arthroplasty. A Short and Mid-Term Follow-Up Analysis with Dual Stratification

PURPOSE

To report and compare, according to sex and age, minimum 2-and minimum 5-year patient-reported outcome scores (PROs) and survivorship in a large cohort of patients who underwent primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Data from February 2008 to September 2018 were reviewed. Patients aged 60 and younger who underwent primary hip arthroscopy with minimum 2-year follow-up were included. Exclusion criteria were Tönnis grade >1, hip dysplasia, previous hip conditions, or any labral treatment different than repair. Minimum 5-year PROs were also collected. All patients included were divided into groups by sex. For further analysis, males and females were stratified according to age: < 21 years old, 21-30 years old, 31-40 years old, 41-50 years old, and 51-60 years old.

RESULTS

In total, 1,326 hips had minimum 2-year follow-up, including 860 (64.9%) females and 466 males (35.1%), with a mean age of 31.6 years (range, 12.8-60.9 years) and a mean follow-up of 58.7 ± 28.9 months. Of those, 772 had minimum 5-year follow-up, 515 females (66.7%), and 257 males (33.3%) with a mean age of 31.7 years (range, 13.1-60.7 years) and a mean follow-up of 78.5 ± 23.0 months. All patients showed significant improvements in PROs at minimum 2-and 5-year follow-up (P < .001). Between sex analysis revealed comparable PROs at latest follow-up between females and males across any age group. Within sexes, and when sexes were combined, patients <21 years old had significantly better outcomes compared to other age groups. There were more females <21 years old that required revision arthroscopy than males <21 years old (P = .015). Conversion to total hip arthroplasty (THA) showed no significant difference between sexes (P > .05). Rates of THA were <21 years (.8%), 21-30 years (2.1%), 31-40 years (4%), 41-50 years (8.9%), and 51-60 years (14.3%).

CONCLUSIONS

Following primary hip arthroscopy for FAIS, all patients reported significant improvements in all PROs at minimum 2-and minimum 5-year follow-up, with females and males achieving similar success. Age affected outcomes, with patients under 21 years old reporting better scores regardless of sex. Although the conversion rate to THA was similar between the sexes, it was lower in the younger ages groups in both sexes.

LEVEL OF EVIDENCE

III, retrospective comparative observation trial.

Hip Arthroscopy Results in Similar Short-Term Function Compared to THA in Patients of Similar Demographic Profiles

Purpose

To review short-term functional outcomes in patients who underwent hip arthroscopy and to compare their outcomes to those of a demographically similar cohort who underwent total hip arthroplasty (THA).

Methods

Data were prospectively collected and retrospectively reviewed for patients undergoing hip arthroscopy (SCOPE) between April 2008 and October 2015. SCOPE patients were included if they were ≥35 years, had preoperative and postoperative 2-year follow-up, and had no prior hip condition or ipsilateral hip surgery. SCOPE patients were matched 1:1 to a demographically similar cohort of patients who underwent THA at our institution. Matching criteria included similar age (within 5 years), gender, and body mass index (within 5). SCOPE patients were assessed with modified Harris Hip Score (mHHS), non-arthritic hip score, and visual analogue scale (VAS). THA patients were assessed with mHHS, forgotten joint score, and VAS.

Results

Sixty-seven patients were included in each cohort. Patients who underwent hip arthroscopy for management of labral tears achieved nearly equivalent mHHS, Health Survey Short Form (SF-12) Mental, SF-12 Physical, Veterans RAND 12 Item Health Survey (VR-12) Mental, VR-12 Physical scores at latest follow-up compared to demographically similar patients who underwent THA. There was no significant difference in mHHS scores (SCOPE = 82.9 ± 16.4 vs THA = 87.3 ± 15, P = .095) between the 2 group groups. In addition, average patient satisfaction on a 10-point scale was 8.1 for the SCOPE cohort and 8.8 for the THA cohort (P = .052).

Conclusions

Our results show that hip arthroscopy, when performed in patients with the appropriate indications, can lead to comparably excellent outcomes as total hip arthroplasty with significant pain relief at short term follow-up.

Level of Evidence

Level III, retrospective cohort study.

Younger Age, Capsular Repair, and Larger Preoperative Alpha Angles Are Associated With Earlier Achievement of Clinically Meaningful Improvement After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

The purpose of the study was to analyze demographic, radiographic, and intraoperative factors that influence the time to achieve the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold (MOIT) after primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear.

METHODS

Included patients had undergone hip arthroscopy with labral repair or reconstruction for FAIS with labral tear between February 2008 and October 2018. Patients were excluded if they had a prior ipsilateral hip surgery, prior hip conditions, a Tonnis grade > 1, or were unwilling to participate. Multiple demographic, radiographic, and intraoperative variables were collected. The modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS) were collected before surgery and at 3 months, 1 year, and 2 years after surgery. The MCID and MOIT for the mHHS and NAHS were either calculated or determined through previously published values. A time-to-event analysis was performed to determine variables predictive of early or delayed achievement of MCID or MOIT. Early achievement was defined as achieving MCID or MOIT at the 3-month timepoint.

RESULTS

Six hundred thirty-two hips (632 patients) were included. Of those that achieved MCID and MOIT, 428 (73.0%) and 414 (73.0%) patients achieved MCID and 253 (47.9%) and 264 (52.5%) patients achieved MOIT by 3 months after surgery for mHHS and NAHS, respectively. Younger age, capsular repair, and increasing alpha angle were associated with earlier achievement for either MCID or MOIT. Increasing age, worker's compensation claims, and higher baseline patient-reported outcome measure scores were associated with delayed achievement for either MCID or MOIT.

CONCLUSIONS

Most of the patients who achieved MCID and MOIT for mHHS and NAHS did so by 3 months after surgery. Younger age, capsular repair, and increasing alpha angle were associated with earlier achievement of MCID and MOIT after hip arthroscopy.

LEVEL OF EVIDENCE

Level IV, case series.

Editorial Commentary: Earlier Hip Arthroscopy May Result in Improved Outcomes for Femoroacetabular Impingement Syndrome in Symptomatic Athletes: No Time Like the Present Could Mean Better Luck Next Year

Hip arthroscopy is an effective tool to address hip pain and dysfunction related to femoroacetabular impingement syndrome (FAIS), and an increasing volume of evidence suggests improved outcomes of these procedures if they are done closer to the onset of symptoms. Although this same relationship is observed in competitive athletes, these patients often have competing priorities when deciding if and when to proceed with surgical management of FAIS, including the desire to complete a competitive season, scouting and scholarship considerations, and financial incentives. Despite these incentives, consideration may be given to earlier surgical management, given the improved outcome potential and high rates of return to play. However, caution should be taken, particularly in the elite athlete population, as return to play data may not paint the whole picture, and there remains a paucity of data on sport performance after hip arthroscopy for FAIS.

The minimal clinically important difference for the nonarthritic hip score at 2-years following hip arthroscopy

PURPOSE

The purpose of this study was to determine and establish the MCID for the NAHS at 2 years in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS).

METHODS

Patients that underwent primary hip arthroscopy for FAIS between 2010 and 2016 were analyzed for eligibility. Data were collected from a single surgeon's hip arthroscopy database. MCID was calculated for the NAHS utilizing a distribution-based method.

RESULTS

The study included 298 patients (184 females) with an average age of 40.4 ± 13.0 years and average body mass index (BMI) of 25.7 ± 4.2 kg/m². At baseline, the cohort's average NAHS score was 48.7 ± 13.6 and demonstrated an improvement of 36.5 ± 17.0 for NAHS at follow-up. This resulted in MCID values of + 8.5 for NAHS.

CONCLUSION

This is the first study to report the MCID (+ 8.5) for NAHS following primary hip arthroscopy, and as such, is a valuable contribution to future hip arthroscopy research.

LEVEL OF EVIDENCE

IV.

Outcomes After Primary Hip Arthroscopy in Athletes Older Than 40 Years Compared With Nonathletes

BACKGROUND

Master athletes (MAs), or athletes older than 40 years, make up a patient population whose outcomes after primary arthroscopic hip surgery are largely unknown.

PURPOSE

To report minimum 2-year outcomes of MAs after primary hip arthroscopy and compare their results to a propensity-matched nonathlete (NA) control group.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected between February 2008 and April 2019 and retrospectively reviewed for all patients who underwent primary hip arthroscopy. Patients were included if they were older than 40 years and had preoperative data for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sports Specific Subscale, and visual analog scale score for pain. MAs reported participating in organized sports competition within 1 year before surgery and were propensity matched to a control group of patients who did not report participating in organized sports competition (NAs). Patient characteristics, radiographic and intraoperative findings, surgical procedures performed, and patient-reported outcome measures (PROMs) were reported and compared between the groups. The rates of achieving the minimal clinically important difference and maximum outcome improvement satisfaction threshold were recorded.

RESULTS

A total of 366 hips were eligible; 328 (89.6%) had adequate follow-up data. 328 patients met inclusion criteria but 88 were not included due to the restrictions of the propensity score match ratio. Of these, 80 hips (76 patients) were classified as MAs (mean age, 48.9 ± 6.2 years) and were propensity matched 1:2 to an NA control group. Groups were comparable for baseline demographic and radiographic parameters, intraoperative findings, and procedures performed. MAs had significantly better baseline and minimum 2-year PROM scores (P < .05), higher satisfaction (P = .01), and higher rates of achieving clinically meaningful improvement across all the outcome tools used (P < .05). MAs, when compared with NAs, had lower rates of secondary arthroscopy (0% vs 7.5%, respectively; P = .001) and conversion to total hip arthroplasty (12.5% vs 26.9%, respectively; P = .011).

CONCLUSION

MAs demonstrated favorable outcomes after primary hip arthroscopy. When compared with a propensity score-matched control group of NA patients, MAs demonstrated better preoperative and postoperative PROMs, higher rates of clinically meaningful improvement, and lower rates of secondary arthroscopy and conversion to total hip arthroplasty. Absolute improvements in PROM scores were similar between the groups.

Earlier Treatment Yields Superior Outcomes in Competitive Athletes Undergoing Primary Hip Arthroscopy

PURPOSE

To report minimum 2-year patient-reported outcome scores (PROs) and return to sport (RTS) for competitive athletes undergoing primary hip arthroscopy for femoroacetabular impingement syndrome within 1 year of symptom onset and to compare these results with a propensity-matched control group of competitive athletes with symptoms for over 1 year.

METHODS

Data on professional, collegiate, high-school, and organized amateur athletes who underwent primary hip arthroscopy within 1 year of symptom onset between April 2008 and November 2017 were collected. RTS and minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), Hip Outcome Score-Sport Specific Subscale (HOS-SSS), International Hip Outcome Tool (iHOT-12), and visual analog pain scale (VAS). Rates of achieving minimal clinically important difference (MCID) were also evaluated. These patients were propensity-matched to a control group of competitive athletes with symptoms for over one year for comparison.

RESULTS

Fifty competitive athletes (51 hips, 54.9% female) were included in the study group with a mean follow-up of 70.9 ± 29.1 months and age of 23.6 ± 11.3 years. They demonstrated significant improvement from preoperative to latest follow-up for all recorded PROs (P < .001) and RTS at a rate of 72.9%. When outcomes were compared to the control group, the study group demonstrated similar preoperative scores for all PROs but significantly better minimum 2-year postoperative scores for NAHS (93.8 vs 85.1, P = .0001), HOS-SSS (89.1 vs 77.2, P = .001), iHOT-12 (87.7 vs 76.4, P = 0.011), and VAS (1.5 vs 2.4, P = 0.027). Rates of achieving MCID for HOS-SSS and mHHS were comparable between groups. Further, RTS rates were similar between groups (P = .301).

CONCLUSION

Competitive athletes undergoing primary hip arthroscopy with symptoms for less than 1 year demonstrated superior 2-year PROs compared to a propensity-matched control group with symptoms for over 1 year, but the rates achieving MCID and RTS were similar between groups.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Outcomes and Return-to-Sport Rates for Elite Athletes With Femoral Retroversion Undergoing Hip Arthroscopy: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background:

Return to sports (RTS) and patient-reported outcomes (PROs) for elite athletes with femoral version abnormalities undergoing hip arthroscopy have not been well established.

Purposes:

To (1) report minimum 2-year PROs and RTS rates in elite athletes with femoral retroversion who underwent primary hip arthroscopy and (2) compare clinical results to those of a propensity-matched control group of elite athletes with normal femoral version who underwent primary hip arthroscopy.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were prospectively collected and retrospectively reviewed for elite (professional and collegiate) athletes with femoral version <5°, as measured on magnetic resonance imaging scans, who underwent hip arthroscopy for femoroacetabular impingement syndrome between March 2010 and April 2018. Inclusion criteria were preoperative and minimum 2-year follow-up PROs for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and visual analog scale for pain. Exclusion criteria were Tönnis grade >1, hip dysplasia, and previous ipsilateral hip surgery or conditions. Rates of achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold were recorded in addition to RTS. Athletes with retroversion were propensity matched in a 1:2 ratio to elite athletes with normal femoral version (5°-20°) for comparison.

Results:

A total of 33 elite athletes (33 hips) with femoral retroversion who underwent hip arthroscopy met the inclusion criteria, and follow-up was available for 30 hips in 30 athletes (90.9%) at an average of 36.1 ± 25.6 months. Elite athletes with femoral retroversion demonstrated significant improvements in all recorded PROs, achieved the MCID and PASS for the HOS-SSS at high rates (86.7%), and returned to sports at a rate of 83.3%. PROs, rates of achieving MCID and PASS for the HOS-SSS, and RTS rates were similar between the study and propensity-matched control group.

Conclusion:

Elite athletes with femoral retroversion undergoing primary hip arthroscopy demonstrated favorable PROs and high RTS rates at a minimum 2-year follow-up. These results were comparable with those of a propensity-matched control group of elite athletes with normal femoral version.

Sex-Based Differences in Athletes Undergoing Primary Hip Arthroscopy With Labral Reconstruction: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

Background:

There is a paucity of literature comparing sex-based outcome differences in athletes after primary hip arthroscopy with labral reconstruction for femoroacetabular impingement syndrome (FAIS) and irreparable labral tears.

Purpose:

To report sex-based differences in clinical characteristics, patient-reported outcome (PRO) scores, and return-to-sports (RTS) rates in athlete who underwent primary hip arthroscopy with labral reconstruction.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were reviewed for recreational, organized amateur, high school, collegiate, and professional athletes who underwent primary hip arthroscopy with labral reconstruction for FAIS and irreparable labral tears between July 2014 and May 2019. Inclusion criteria included preoperative and minimum 2-year postoperative PRO scores (modified Harris Hip Score, Non-Arthritic Hip Score, Hip Outcome Score–Sports Specific Subscale, International Hip Outcome Tool [iHOT-12], and visual analog scale [VAS] for pain). Exclusion criteria were Tönnis grade >1, hip dysplasia (lateral center-edge angle, <18°), or prior ipsilateral hip surgery/conditions. Patients were divided into groups by sex and were propensity-matched in a 1:1 ratio by age, body mass index, graft type, labral tear size, and sports level.

Results:

A total of 101 hips were eligible, and 94 hips (93.1%) had a minimum 2-year follow-up. Twenty-nine female athlete hips were propensity-matched to 29 male athlete hips. Female athletes underwent higher rates of capsular repair (79.3% vs 24.1% for men; P < .001) and lower rates of acetabular microfracture (0.0% vs 20.7% for men; P = .024). Both female and male athletes experienced significant improvement on all PRO scores (P < .001 for all), high RTS rates (women, 84% vs men, 80.8%), and high rates of achieving the minimal clinically important difference for the iHOT-12 and VAS pain (women, 88.5% vs men, 71.4% for both) and achieving the patient acceptable symptom state for the iHOT-12 (women, 88.5% vs men, 71.4%), with no significant difference between the sexes.

Conclusion:

Despite different clinical characteristics and surgical procedures, both female and male athletes undergoing primary hip arthroscopy with labral reconstruction had significant improvements in all PROs at the minimum 2-year follow-up, high RTS rates, and similar rates of achieving the minimal clinically important difference and patient acceptable symptom state.

Basketball Players Undergoing Primary Hip Arthroscopy Exhibit Higher Grades of Acetabular Cartilage Damage but Achieve Favorable Midterm Outcomes and Return to Sports Rates Comparable With a Propensity-Matched Group of Other Cutting Sports Athletes

BACKGROUND

Favorable short-term outcomes in competitive basketball players have been reported. Midterm outcomes in these athletes and how they compare with athletes in sports with similar demands have not been well established.

PURPOSE

(1) To report minimum 5-year patient-reported outcomes (PROs) and return to sports data in competitive basketball players undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to compare outcomes with a propensity-matched control group of other cutting sports athletes.

STUDY DESIGN

Cohort study, Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for basketball players who competed at the professional, collegiate, high school, or competitive amateur levels and underwent primary hip arthroscopy for FAIS between May 2009 and March 2016. Patients with preoperative and minimum 5-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain were included. Patients were propensity matched to athletes in other cutting sports (soccer, lacrosse, field hockey, and tennis) according to age, sex, body mass index (BMI), and preoperative competition level for comparison.

RESULTS

A total of 28 competitive basketball players were included, with a mean follow-up time of 67.1 ± 5.1 months and a mean BMI of 23.7 ± 4; there were 12 (42.9%) female athletes. The cohort was composed of 1 professional, 10 collegiate, 13 high school, and 4 organized amateur athletes. They demonstrated significant improvements in all recorded PROs from baseline to the minimum 5-year follow-up (P < .001) and had high rates of achieving the minimal clinically important difference (MCID) for the mHHS (75%), NAHS (75%), HOS-SSS (67.9%), and VAS for pain (71.4%). Furthermore, 76.5% of basketball players who returned to sports were still competing at a minimum of 5 years postoperatively. When compared with a propensity-matched cohort of other cutting athletes, basketball athletes demonstrated a significantly higher acetabular labrum articular disruption (ALAD) grade (P < .001) and trended toward a higher Outerbridge grade of the acetabular cartilage (P = .067). Despite this, basketball players demonstrated similar preoperative, postoperative, and improvement scores in all recorded PROs. Moreover, both groups exhibited similar rates of achieving psychometric thresholds and rates of continued sports participation at minimum 5-year follow-up.

CONCLUSION

Competitive basketball players undergoing primary hip arthroscopy for FAIS demonstrated significant improvements in all recorded PROs and high rates of continued play at a minimum 5-year follow-up. When compared with a control group of other cutting sports athletes, basketball players exhibited more severe ALAD grades intraoperatively but similar midterm outcomes.

Comparison of Outcomes Between Nonsmokers and Patients Who Discontinued Smoking 1 Month Before Primary Hip Arthroscopy: A Propensity-Matched Study With Minimum 2-Year Follow-up

Background:

Cigarette smoking has been shown to negatively affect outcomes after hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The effect of cessation of cigarette smoking before surgery has not been well established.

Purposes:

(1) To report minimum 2-year patient-reported outcomes (PROs) of former smokers who underwent primary hip arthroscopy for FAIS and (2) to compare these results with those of a propensity-matched control group of nonsmokers.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Data were collected for all patients who underwent primary hip arthroscopy for FAIS between December 2008 and November 2017. Patients were eligible if they indicated that they had previously smoked cigarettes but had quit smoking at least 1 month before surgery and had minimum 2-year postoperative outcomes for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and visual analog scale (VAS) for pain. The percentage of hips achieving the minimal clinically important difference (MCID) were recorded. The study group was then propensity matched in a 1:1 ratio by age, sex, and body mass index (BMI) to patients who had never smoked.

Results:

A total of 83 former-smoking patients (84 hips; age, 45.0 ± 13.5 years) were included at a median follow-up of 38.6 months (interquartile range, 27.5-48.2 months); all patients had stopped smoking at a mean ± standard deviation of 14.3 ± 24.5 months preoperatively. Former smokers demonstrated significant improvement from preoperatively to the minimum 2-year follow-up for all recorded PROs (P < .001 for all) and achieved the MCID for the mHHS, NAHS, and VAS at favorable rates (75.0%-81.6%). Logistic regression analysis did not identify a significant relationship between cessation time and rates of achieving MCID for mHHS, NAHS, or VAS. When compared with 84 never-smokers (84 hips), the former smokers demonstrated similar preoperative scores, postoperative scores, and improvement on all recorded PROs (P > .05 for all). Both groups achieved MCID for mHHS, NAHS, and VAS at similar rates and demonstrated similar rates of revision surgery.

Conclusion:

Former smokers who underwent primary hip arthroscopy for FAIS demonstrated significant improvement in PROs at minimum 2-year follow-up. When compared with a propensity-matched control group of never-smokers, they achieved similar postoperative PROs and rates of achieving psychometric thresholds.

High-Level Athletes Who Did Not Return to Sport for Reasons Unrelated to Their Hip Achieve Successful Midterm Outcomes With a Benchmarking Against High-Level Athletes Who Returned to Sport

PURPOSE

1) To report minimum 2- and 5-year outcomes of high-level athletes who did not return to sport (RTS) after hip arthroscopy for reasons unrelated to their hip (T athletes) and 2) to benchmark these findings against a propensity-matched control group of high-level athletes who returned to sport (RTS athletes).

METHODS

Data were prospectively collected and retrospectively reviewed for professional, collegiate, and high school athletes between April 2008 and October 2015, who underwent primary hip arthroscopy. Athletes were considered eligible if they did not return to sport for reasons unrelated to their hip such as loss of interest, graduation, or a lifestyle transition (T athletes). Inclusion criteria were preoperative and minimum 5-year postoperative patient-reported outcomes (PROs) for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and the visual analog scale (VAS) for pain. Clinical outcomes were assessed using the minimal clinically important difference (MCID) and maximum outcome improvement satisfaction threshold (MOIST). T athletes were then propensity-matched to a control group of high-level athletes who returned to sport after hip arthroscopy (RTS athletes) for comparison.

RESULTS

Twenty-seven T hips (25 patients) were included in the analysis with a mean follow-up time of 38.9 ± 16.8 and 72.1 ± 16.8 months for minimum 2- and 5-year outcomes, respectively. They demonstrated significant improvement in all measured PROs. When compared to a propensity-matched control group of RTS athletes, T athletes demonstrated similar improvement in PROs (mHHS, NAHS, and HOS-SSS) and achieved MCID at similar rates for NAHS (T: 77.8% vs RTS: 68.8%; P = .570) and HOS-SSS (T: 70.3% vs RTS: 76.6%, P = .824) compared to RTS athletes; however T athletes demonstrated higher rates of achieving MCID for mHHS (T: 88.9% vs RTS: 72.9% P = .033).

CONCLUSION

Athletes who did not return to sport for reasons unrelated to their hip demonstrated favorable outcomes at minimum 2- and 5-year follow-up. They had similar PROs and rates of achieving MCID for HOS-SSS compared to a propensity-matched control group of high-level athletes who returned to sport. Return to sport status may not necessarily be correlated to the patient's perception of their own outcome.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Routine Capsular Closure With Hip Arthroscopic Surgery Results in Superior Outcomes: A Systematic Review and Meta-analysis

BACKGROUND

In hip arthroscopic surgery, capsulotomy is performed to improve visualization and allow instrumentation of the joint. Traditionally, the defect has been left unrepaired; however, increasing evidence suggests that this may contribute to persistent pain and iatrogenic capsular instability. Nevertheless, the clinical benefit of performing routine capsular repair remains controversial.

PURPOSE/HYPOTHESIS

We conducted a systematic review and meta-analysis to investigate the effects of routine capsular closure on patient-reported outcomes (PROs), hypothesizing that superior PROs would be observed with routine capsular closure.

STUDY DESIGN

Meta-analysis and systematic review; Level of evidence, 4.

METHODS

A systematic review and meta-analysis was conducted according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The terms "hip,""arthroscopy,""capsule,""capsular,""repair," and "closure" were used to query Ovid MEDLINE, Embase, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), SPORTDiscus, and PubMed. Articles with PROs stratified by capsular management were included. Multivariate mixed-effects metaregression models were implemented with study-level random-effects and fixed-effects moderators for capsular closure versus no repair and after controlling for surgical indication and preoperative PROs. The effect of repair on both the postoperative score and the change in scores was evaluated via the Harris Hip Score (HHS)/modified HHS (mHHS), Hip Outcome Score (HOS)-Activities of Daily Living (ADL), and HOS-Sport Specific Subscale (SSS), with a supplemental analysis of additional outcomes.

RESULTS

Of 432 initial articles, 36 were eligible for analysis, with results for 5132 hip arthroscopic procedures. The capsule was repaired in 3427 arthroscopic procedures and unrepaired in 1705. Capsular repair was associated with significantly higher postoperative HHS/mHHS (2.011; SE, 0.743 [95% CI, 0.554-3.467]; P = .007), HOS-ADL (3.635; SE, 0.873 [95% CI, 1.923-5.346]; P < .001), and HOS-SSS (4.137; SE, 1.205 [95% CI, 1.775-6.499]; P < .001) scores as well as significantly superior improvement on the HHS/mHHS (2.571; SE, 0.878 [95% CI, 0.849-4.292]; P = .003), HOS-ADL (3.315; SE, 1.131 [95% CI, 1.099-5.531]; P = .003), and HOS-SSS (3.605; SE, 1.689 [95% CI, 0.295-6.915]; P = .033).

CONCLUSION

This meta-analysis is the largest to date evaluating the effect of capsular closure on PROs and demonstrates significantly higher mean postoperative scores and significantly superior improvement with repair, while controlling for the effects of preoperative score and surgical indication. The true magnitude of the benefit of capsular repair may be clarified by large prospective randomized studies using PRO measures specifically targeted and validated for hip arthroscopic surgery/preservation.

Revision Hip Arthroscopy With Labral Reconstruction for Irreparable Labral Tears in Athletes: Minimum 2-Year Outcomes With a Benchmark Control Group

BACKGROUND

The incidence of revision hip arthroscopy with labral reconstruction in athletes is increasing. However, the outcomes of revision hip arthroscopy with labral reconstruction in athletes have not been well established.

PURPOSES

(1) To report minimum 2-year patient-reported outcome (PRO) scores and return to sports (RTS) characteristics for high-level athletes undergoing revision hip arthroscopy with labral reconstruction and (2) to compare clinical results with those of a propensity-matched control group of high-level athletes undergoing revision hip arthroscopy with labral repair.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for athletes at any level who underwent a revision hip arthroscopy and a labral reconstruction between April 2010 and March 2019. Minimum 2-year PROs were reported for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sport Specific Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and RTS. The percentages of athletes achieving the minimal clinically important difference (MCID) and the maximum outcome improvement satisfaction threshold (MOIST) were also recorded. These patients were propensity matched in a 1: 1 ratio to athletes undergoing revision hip arthroscopy with labral repair for comparison.

RESULTS

A total of 46 athletes (N = 47 hips) were reported from 50 (n = 51 hips) athletes who underwent revision with labral reconstruction. A subanalysis of 30 propensity-matched athletes undergoing revision labral reconstruction was performed, with a mean follow-up time of 26.3 ± 2.4 months and an age of 28.5 ± 10.1 years, and compared with a revision labral repair group. Significant improvements were obtained for the mHHS, the NAHS, the HOS-SSS, and the VAS from preoperative to the latest follow-up (P < .001), with an achievement MCID rate of 61.5%, 72%, 62.5%, and 76.9% for the mHHS, the NAHS, the HOS-SSS, and the VAS, respectively. The rate for re-revision surgery (2 tertiary arthroscopy and 1 conversion to total hip arthroplasty) was 10%, and 14 patients (63.6%) were able to RTS. Improvements in PROs, rates of achieving MCID/MOIST, rate of re-revision surgery (re-revision hip arthroscopy, P = .671; conversion to total hip arthroplasty, P > .999), and RTS rate (P = .337) were similar when compared with those of the propensity-matched control labral repair group (P > .05).

CONCLUSION

Revision hip arthroscopy with labral reconstruction, in the context of an irreparable labral tear, seems to be a valid treatment option in the athletic population, demonstrating significant improvements in all PROs and low rates of undergoing revision surgery. Athletes experienced a similar magnitude of improvement in PROs, RTS rate, and revision surgery rate to that of a propensity-matched control group of athletes undergoing revision hip arthroscopy with labral repair.

Competitive Athletes with Femoroacetabular Impingement and Painful Internal Snapping Treated Arthroscopically with Intrabursal Iliopsoas Fractional Lengthening: High Rate of Return to Sport and Favorable Midterm Functional Outcomes

BACKGROUND

Athletes with femoroacetabular impingement syndrome (FAIS) who undergo hip arthroscopy with iliopsoas fractional lengthening (IFL) in the context of painful internal snapping have demonstrated favorable patient-reported outcomes (PROs), return to sport (RTS), and resolution of internal snapping symptoms at short term follow-up. Midterm outcomes have not been established.

PURPOSES

(1) To report minimum 5-year PROs and RTS rate in competitive athletes who underwent primary hip arthroscopy for FAIS and intra-bursal IFL for painful internal snapping and (2) to compare these clinical results with those of a propensity score-matched control group of competitive athletes who underwent primary hip arthroscopy without painful internal snapping and IFL.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were reviewed for consecutive surgeries performed by a single surgeon between February 2010 and December 2013. Patients were considered eligible if they were professional, collegiate, or high school athletes and received a primary hip arthroscopy for FAIS and intra-bursal IFL without extended capsulotomy for painful internal snapping. Indications for IFL were painful internal snapping on preoperative physical examination. Inclusion criteria were preoperative and minimum 5-year follow-up scores for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain. Rates of achieving the minimal clinically important difference were also reported. For comparison, athletes in the IFL group were propensity matched by age, sex, body mass index, lateral and anterior center-edge angles, and sports level to a control group of athletes without internal snapping who underwent primary hip arthroscopy for FAIS without IFL.

RESULTS

A total of 105 competitive athletes in the IFL group were included in the study with a follow-up of 66.8 ± 6.9 months (mean ± SD). The IFL cohort showed significant improvement in all recorded PROs at minimum 5-year follow-up (P < .001). Furthermore, they demonstrated favorable rates of achieving the minimal clinically important difference for the modified Harris Hip Score (82.0%), Nonarthritic Hip Score (85.4%), and Hip Outcome Score-Sport Specific Subscale (82.8%). Further, 89.5% of athletes in the IFL cohort successfully returned to sport. A total of 42 athletes in the IFL group were propensity matched to 54 control athletes. When groups were compared, they demonstrated similar improvement in PROs and rates of RTS, revision arthroscopy, and achieving psychometric thresholds.

CONCLUSION

Competitive athletes undergoing primary hip arthroscopy and intra-bursal IFL in the context of FAIS and painful internal snapping demonstrated favorable PROs and RTS rate at minimum 5-year follow-up. These results were comparable with those of a control group of athletes not requiring IFL.

Postoperative Alpha Angle Is Predictive of Return to Sport in Athletes Undergoing Hip Arthroscopy for Femoroacetabular Impingement

PURPOSE

To identify clinical and radiographic factors that predict return to sport in athletes undergoing hip arthroscopy and to determine thresholds for significant predictors.

METHODS

Data were reviewed on all patients who underwent primary hip arthroscopy between November 2008 and August 2018. Patients were included if they played professional, college, or high school sports within 1 year before surgery and had preoperative, 3-month, 1-year, and 2-year postoperative patient-reported outcome scores for modified Harris Hip Score, Hip Outcome Score-Sport Specific-Subscale, and Nonarthritic Hip Score. Rates of achieving the minimal clinically important difference also were evaluated. Patients were divided into groups based on whether they returned to sport at the same or greater level. Multivariate logistic regression and receiver operator characteristic analysis were used to evaluate the correlation between significant variables and return to sport.

RESULTS

A total of 136 patients with a mean age of 20.8 ± 7.07 years were included. Among athletes who attempted to return, professional and collegiate athletes returned to sport at any level at a rate of 85.0% (51/60), and high-school athletes returned at a rate of 88.1% (52/59). Competition level, postoperative alpha angle, change in alpha angle, and postoperative patient-reported outcomes were significantly different between groups. Athletes who returned to sport achieved the minimal clinically important difference for Hip Outcome Score-Sport Specific-Subscale at significantly higher rates than athletes who did not return to sport (91.6% vs 71.7%, P = .002, S = 8.97). The multivariate logistic regression model identified postoperative alpha angle as a statistically significant predictor of return to sport (P < .001, S > 9.97 [odds ratio 0.85, 95% confidence interval 0.79-0.91]). The receiver operator characteristic curve for postoperative alpha angle demonstrated acceptable discrimination between patients returning to sport and patients not returning to sport with an area under the curve of 0.71 and a threshold value of 46°. Athletes with a postoperative alpha angle ≤46° returned to sport at significantly higher rates than those with a postoperative alpha angle >46° [(P < .001, S > 9.97 [odds ratio 6.3, 95% confidence interval 2.6-15.2]).

CONCLUSIONS

Postoperative alpha angle was identified as a predictor of return to sport in athletes. The odds of returning to sport were 6.3 times greater in athletes with postoperative alpha angles ≤46° compared with athletes with angles >46°.

LEVEL OF EVIDENCE

III, retrospective cohort study.

Dunn View Alpha Angle More Useful Than Femoral Head-Neck Offset to Predict Acetabular Cartilage Damage in Patients With Femoroacetabular Impingement Syndrome Undergoing Hip Arthroscopy

PURPOSE

To identify radiographic measurements and demographics that are predictive of acetabular cartilage damage in patients with femoroacetabular impingement syndrome (FAIS) undergoing hip arthroscopy. More specifically, to compare the predictive value of alpha angle and femoral head-neck offset, as measured on Dunn view radiographs, in determining the preoperative likelihood and severity of acetabular cartilage damage.

METHODS

Patients were included if they underwent primary hip arthroscopy for FAIS between February 2008 and June 2020. Exclusion criteria were prior ipsilateral hip conditions, Tönnis grade of osteoarthritis >1, unwilling to participate, missing intraoperative, demographic or radiographic variables of interest, and lateral center-edge angle (LCEA) >40° or ≤25°. Fourteen variables were assessed in a bivariate comparison and analyzed in a multivariate logistic model. The Acetabular Labrum Articular Disruption (ALAD) and Outerbridge (OB) classifications were used to define acetabular cartilage defects. Those without damage or those with mild acetabular cartilage damage belonged to the ALAD/OB ≤2 group and those with severe damage belonged to the ALAD/OB ≥ 3 group.

RESULTS

A total of 1485 patients were analyzed, including 1038 patients with ALAD/OB ≤2 and 447 patients with ALAD/OB ≥3. There was a greater proportion of males in the ALAD/OB ≥3 group (64.21% vs 25.82%; P <.001). The multivariate logistic regression selected age, sex, anterior center-edge angle (ACEA), and alpha angle. Every additional degree in the alpha angle was associated with a 6% increase in the odds of severe acetabular cartilage damage (odds ratio [OR], 1.06 [95% confidence interval [CI], 0.12-8.11]). The multivariate analysis did not identify femoral head-neck offset as a predictor. The odds of severe acetabular cartilage damage were 3.73 times higher in males than females (OR, 3.73 [95% CI, 0.01-1705.96]). Higher age was found to increase the likelihood of ALAD/OB ≥3 (OR, 1.04 [95% CI, 0.13-7.75]).

CONCLUSIONS

In a multivariate analysis, factors identified as preoperative predictors of acetabular cartilage damage in patients with FAIS were age, sex, ACEA, and alpha angle. Femoral head-neck offset was not predictive, suggesting that Dunn view alpha angle may take precedence as a predictor of acetabular cartilage damage.

LEVEL OF EVIDENCE

Level III, cohort study.

Workers' Compensation Patients Improved After Hip Arthroscopy for Labral Tears: A 5-Year Outcome Propensity Score-Matched Study

BACKGROUND

The workers' compensation (WC) status has been associated with inferior outcomes in orthopaedic procedures and is usually excluded from clinical outcome studies. Therefore, comparative studies based on WC status are scarce.

PURPOSE

(1) To determine outcomes of patients with WC claims treated with hip arthroscopy for labral tears at a minimum 5-year follow-up and (2) to compare these findings with a propensity score-matched control group without WC claims.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients were propensity score matched to a control group without WC claims. Data were prospectively collected for all patients undergoing hip arthroscopy. Patients were included if they received primary hip arthroscopy for labral tears in the setting of femoroacetabular impingement, had a WC claim, and had preoperative and minimum 5-year follow-up patient-reported outcomes ([PROs]; modified Harris Hip Score [mHHS], Non-Arthritic Hip Score [NAHS], Hip Outcome Score-Sports Specific Subscale [HOS-SSS], and visual analog scale [VAS] for pain). Clinical outcomes were measured using the Patient Acceptable Symptom State (PASS), minimal clinically important difference (MCID), and maximum outcome improvement satisfaction threshold (MOI).

RESULTS

A total of 111 from 132 (84.1%) eligible WC patients met the inclusion criteria with an average follow-up time of 80.3 ± 37.3 months. WC cases demonstrated significant improvement from preoperatively to a minimum 5-year follow-up for mHHS, NAHS, HOS-SSS, and VAS for pain (P < .05). WC patients returned to work at a 66% rate, with an average clearance time of 4.7 months to light duty and 9.5 months to heavy duty. When compared with the control group, the WC group demonstrated lower pre- and postoperative PROs (P < .05); however, WC cases had a greater magnitude of improvement (ΔmHHS [P = .0012], ΔNAHS [P < .001], and ΔHOS-SSS [P = .012]). Rates of achieving MCID and MOI were similar in both groups (P > .05). The WC group went on to receive a future arthroscopy in 19 cases (17.1%), while 10 cases (4.5%) in the control group required revision arthroscopy (P < .001). Patients in both the WC and the control groups converted to total hip arthroplasty at similar rates (13.3% and 15.4%, respectively; P > .05).

CONCLUSION

Patients with WC claims treated with hip arthroscopic surgery showed significant improvement and high rates of returning to work at a minimum 5-year follow-up. Although having lower scores in PROs and achieving PASS rates, no differences were found in MCID and MOI rates. Furthermore, WC patients had a greater magnitude of improvement from preoperatively to a minimum 5-year follow-up after hip arthroscopy. Therefore, even though more studies are needed to determine the causes of inconsistent outcomes in the WC population, hip arthroscopy can effectively treat labral tears in the setting of femoroacetabular impingement, regardless of the WC status.

Preoperative Alpha Angles Can Predict Severity of Acetabular Rim Chondral Damage in Symptomatic Cam-Type Femoroacetabular Impingement: A Prospective Observatory Study

PURPOSE

To identify the relationship between the alpha angle and the severity of chondrolabral separation as well as acetabular rim chondral damage in symptomatic cam-type femoroacetabular impingement (FAI) with or without focal pincer-type FAI.

METHODS

Patients who received hip arthroscopy under the diagnosis of symptomatic cam-type FAI between January 2018 and August 2018 were identified in a prospectively collected database. Patients were excluded if preoperative lateral center-edge angle <25°, lateral center-edge angle ≥40°, Tönnis grade >1, with previous surgery on the affected hip, or with concomitant synovial disease. The chondrolabral junction was classified into intact chondrolabral junction, stable chondrolabral separation and unstable chondrolabral separation. The classification of acetabular rim chondral damage was modified from the MAHORN (Multicenter Arthroscopy of the Hip Outcomes Research Network) classification: normal/softening, bubble, pocket, flap, and exposed bone. The relationship between the hip morphology and severity of chondrolabral junction and acetabular rim chondral damage was assessed.

RESULTS

A total of 71 patients with the mean age of 33.2 ± 11.0 years were included. Preoperative alpha angles on anteroposterior (AP) or Lauenstein view positively correlated with the severity of acetabular rim chondral damage (P = .028 and P = .016, respectively). A significant increment of the alpha angle between 2 consecutive grades of acetabular rim chondral damage was 7.1° (P = .001) on AP view and 5.2° on Lauenstein view (P = .001). The cut-off values for predicting advanced acetabular rim chondral damage (pocket, flap or bony exposure) were an AP alpha angle of 70° (P = .025) and a Lauenstein alpha angle of 57° (P = .003). There was no significant association between the alpha angle and the severity of chondrolabral separation.

CONCLUSIONS

In patients with symptomatic cam-type FAI with or without focal pincer-type FAI, greater preoperative alpha angles on AP and Lauenstein views can predict more severe acetabular chondral damage.

LEVEL OF EVIDENCE

Level III.

Osteochondroplasty Benefits the Pragmatic Patient With Femoroacetabular Impingement: Analysis From the Embedded Prospective Cohort of the Femoroacetabular Impingement RandomiSed Controlled Trial (FIRST)

PURPOSE

To determine whether arthroscopic osteochondroplasty demonstrated effectiveness in a pragmatic femoroacetabular impingement patient population embedded within FIRST (the Femoroacetabular Impingement RandomiSed controlled Trial).

METHODS

All cohort patients were not randomized and were followed prospectively with a follow-up assessment protocol identical to that in FIRST. The primary outcome was hip pain using a 100-point visual analog scale. Secondary outcomes included hip function (Hip Outcome Score, International Hip Outcome Tool-12), health utility (EuroQol 5 Dimensions), and health-related quality of life (Short Form-12) at 12 months, as well as operatively and nonoperatively treated hip complications at 24 months. We performed multivariable regressions to compare these outcomes between 3 groups of patients: (1) those randomized to lavage in FIRST, (2) those randomized to osteochondroplasty in FIRST, and (3) those who received osteochondroplasty as part of the cohort study.

RESULTS

All groups had improvements across all questionnaire outcomes from baseline to 12 months, with no significant differences. There were significantly more reoperations in the lavage trial group compared with those in the embedded cohort (adjusted odds ratio [aOR] 3.08; 95% confidence interval [CI] 1.23-7.73; P = .016). There were significantly more nonoperatively treated hip complications in the lavage trial group and in the osteochondroplasty trial group when compared with those in the embedded cohort (aOR 3.81; 95% CI 1.19-12.17; P = .024 and aOR 4.55; 95% CI 1.43-14.42; P = .010, respectively).

CONCLUSIONS

Hip arthroscopic osteochondroplasty and lavage led to improvement in hip pain, function, and health-related quality of life at 12 months across both randomized controlled trial (RCT) and cohort patients. The pragmatic cohort receiving osteochondroplasty had (1) significantly fewer complications than RCT patients, (2) significantly less reoperations than RCT patients randomized to arthroscopic lavage, and (3) fewer, although nonsignificant, reoperations than RCT osteochondroplasty patients.

LEVEL OF EVIDENCE

II, therapeutic.

Predictors of Achieving the Patient Acceptable Symptomatic State at Minimum 5-Year Follow-up Following Primary Hip Arthroscopy in the Adolescent Athlete

BACKGROUND

Predictors of outcomes in adolescent athletes undergoing hip arthroscopy have not been established. The purpose of this study was to identify factors correlated with achieving the Patient Acceptable Symptomatic State (PASS) for the Hip Outcome Score-Sports Specific Subscale (HOS-SSS) at a minimum 5-year follow-up in adolescent athletes undergoing primary hip arthroscopy.

METHODS

Data were reviewed on adolescent (below 18 y old) athletes who underwent primary hip arthroscopy for femoroacetabular impingement syndrome between March 2008 and October 2015. Patients were included if they participated in sport within 1 year before surgery and had preoperative, 2-year, and minimum 5-year postoperative patient-reported outcome (PRO) scores for the modified Harris Hip Score, HOS-SSS, Visual Analog Scale for pain (VAS), and Non-Arthritic Hip Score (NAHS). Patients were divided into 2 groups based on whether they achieved PASS for HOS-SSS. Demographics, intraoperative findings, radiographic variables, surgical treatments, and PRO were compared. Multivariate logistic regression with corresponding odds ratios (ORs) quantified the correlation between variables and achievement of the PASS.

RESULTS

A total of 123 athletes with a mean age of 16.2±1.1 years were included. These athletes demonstrated significant imrpovement from preoperative to minimum 5-year follow-up for all recorded PROs (P<0.001). The multivariate logistic regression model identified preoperative NAHS (P=0.019, OR: 1.033), 2-year postoperative HOS-SSS (P=0.014, OR: 1.037), and 2-year postoperative VAS (P=0.003, OR: 0.590) as statistically significantly correlated with achieving the PASS. Athletes with a 2-year postoperative VAS pain score ≤2 achieved PASS at a rate of 81.9%, while those with a score >2 achieved PASS at a rate of 24.1% (P<0.001, OR: 14.2, 95% confidence interval: 5.23-38.7).

CONCLUSIONS

Favorable outcome were achieved at mid-term follow-up in adolescent athletes undergoing primary hip arthroscopy. Preoperative NAHS, 2-year postoperative HOS-SSS, and 2-year postoperative VAS pain scores were correlated with achieving the PASS for HOS-SSS at a minimum 5-year follow-up. Patients with 2-year postoperative VAS ≤2 were significantly more likely to achieve the PASS at 5-year follow-up than those with scores >2.

LEVEL OF EVIDENCE

Level III-case-control study.

Pathologic Findings on Hip Arthroscopy in High-Level Athletes Competing in Flexibility Sports

BACKGROUND

Athletes who compete in flexibility sports (FS) place unique demands on their hip joints because of the supraphysiologic range of motion required.

PURPOSE

To compare the pathologic features, outcomes, and return-to-sports (RTS) rates of high-level athletes participating in FS who underwent hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and labral tear against a propensity score-matched cohort of high-level athletes participating in non-flexibility sports (NFS).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for high-level athletes who underwent primary hip arthroscopy for FAIS from April 2008 to December 2018. Patients who participated in FS such as dancing, gymnastics, martial arts, figure skating, and cheerleading were propensity score matched by body mass index, age at time of surgery, sex, sports competition level, and labral treatment to a cohort of high-level athletes participating in all other sports, such as distance running, soccer, volleyball, and softball. Baseline patient characteristics, intraoperative findings, and surgical procedures were compared. Minimum 2-year patient-reported outcome measures were compared for the modified Harris Hip Score, Nonarthritic Hip Score, Hip Outcome Score-Sport Specific Subscale, and visual analog scale for pain and satisfaction. Rates of secondary surgery and RTS were compared.

RESULTS

A total of 47 patients (50 hips) who participated in FS were included and propensity score matched to 130 patients (150 hips) who participated in NFS. Follow-up time was 37.5 ± 10.4 months (mean ± SD). Most patients (96.0%) were female with a mean age of 19.5 ± 7.3 years. FS athletes had significantly higher rates of femoral head cartilage lesions (Outerbridge ≥2; 12.0% vs 2.0%; P = .008) and ligamentum teres tears (48% vs 26%; P = .003). FS and NFS athletes demonstrated significant clinical improvements after surgery for all patient-reported outcome measures. Of the patients who attempted, 34 (75.6%) participating in FS were able to RTS while 11 (24.4%) were not because of ongoing hip issues. This was not significantly different than the NFS group (P = .073).

CONCLUSION

High-level athletes who participated in FS and were treated for FAIS with hip arthroscopy exhibited higher rates of femoral head cartilage lesions and ligamentum teres tears requiring debridement when compared with a benchmark group of athletes who participated in other sports. Despite this, both groups demonstrated similar improvements in outcome scores and comparable rates of RTS at minimum 2-year follow-up.

The Impact of Pre-Operative Healthcare Utilization on Complications, Readmissions, and Post-Operative Healthcare Utilization Following Total Joint Arthroplasty

BACKGROUND

Identifying risk factors for adverse outcomes and increased costs following total joint arthroplasty (TJA) is needed to ensure quality. The interaction between pre-operative healthcare utilization (pre-HU) and outcomes following TJA has not been fully characterized.

METHODS

This is a retrospective cohort study of patients undergoing elective, primary total hip arthroplasty (THA, N = 1785) or total knee arthroplasty (TKA, N = 2159) between 2015 and 2019 at a single institution. Pre-HU and post-operative healthcare utilization (post-HU) included non-elective healthcare utilization in the 90 days prior to and following TJA, respectively (emergency department, urgent care, observation admission, inpatient admission). Multivariate regression models including age, gender, American Society of Anesthesiologists, Medicaid status, and body mass index were fit for 30-day readmission, Centers for Medicare and Medicaid services (CMS)-defined complications, length of stay, and post-HU.

RESULTS

The 30-day readmission rate was 3.2% and 3.4% and the CMS-defined complication rate was 3.8% and 2.9% for THA and TKA, respectively. Multivariate regression showed that for THA, presence of any pre-HU was associated with increased risk of 30-day readmission (odds ratio [OR] 2.85, 95% confidence interval [CI] 1.48-5.50, P = .002), CMS complications (OR 2.42, 95% CI 1.27-4.59, P = .007), and post-HU (OR 3.65, 95% CI 2.54-5.26, P < .001). For TKA, ≥2 pre-HU events were associated with increased risk of 30-day readmission (OR 3.52, 95% CI 1.17-10.61, P = .026) and post-HU (OR 2.64, 95% CI 1.29-5.40, P = .008). There were positive correlations for THA (any pre-HU) and TKA (≥2 pre-HU) with length of stay and number of post-HU events.

CONCLUSION

Patients who utilize non-elective healthcare in the 90 days prior to TJA are at increased risk of readmission, complications, and unplanned post-HU.

LEVEL OF EVIDENCE

Level III.

Low Body Mass Index in Females May Portend Inferior Outcomes After Primary Hip Arthroscopy: A Propensity-Matched Analysis With Minimum 2-Year Follow-up

BACKGROUND

There is a paucity of literature evaluating the effect of low body mass index (BMI) in female patients undergoing primary hip arthroscopy.

PURPOSE

(1) To report minimum 2-year patient-reported outcome scores for female patients with low BMI who underwent primary hip arthroscopy for femoroacetabular impingement syndrome and (2) to compare these results with a propensity-matched control group of female patients with normal BMI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected on all female patients who had low BMI (<18.5) and underwent primary hip arthroscopy between April 2008 and January 2019. Patients were excluded if they had a previous hip arthroscopy; had workers' compensation; were unwilling to participate in the study; or had Tönnis osteoarthritis grade >1, acetabular dysplasia, or a previous hip condition. Minimum 2-year patient-reported outcomes were collected for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score, Hip Outcome Score-Sport Specific Subscale (HOS-SSS), visual analog scale for pain, and satisfaction. The percentage of patients achieving the minimal clinically important difference (MCID), Patient Acceptable Symptom State (PASS), and maximum outcome improvement satisfaction threshold (MOIST) was also recorded. These patients were propensity matched in a 1:2 ratio to female patients with normal BMI for comparison.

RESULTS

A total of 43 patients (49 hips) were included with a mean ± SD follow-up of 26.9 ± 8.3 months, age of 24.1 ± 12.6 years, and BMI of 17.7 ± 0.67. These patients demonstrated significant improvement from presurgery to minimum 2-year follow-up for the mHHS, Non-Arthritic Hip Score, HOS-SSS, and visual analog scale (P < .05). When outcomes were compared with 93 control patients (97 hips), female patients with low BMI demonstrated lower rates of achieving the PASS for the mHHS (61.2% vs 77.3%; P = .041) and HOS-SSS (39.5% vs 57.1%; P = .031). Rates of achieving the MCID and MOIST were similar between the groups (P > .05). Female patients with low BMI also had higher rates of revision when compared with the control group, but this did not reach statistical significance (14.2% vs 7.2%; P = .171).

CONCLUSION

Female patients with low BMI undergoing primary hip arthroscopy for femoroacetabular impingement syndrome demonstrated significant improvement in patient-reported outcomes at minimum 2-year follow-up. When compared with a propensity-matched control group with normal BMI, these patients demonstrated lower rates of achieving the PASS for the mHHS and HOS-SSS. Low BMI in females undergoing primary hip arthroscopy for FAIS may adversely affect outcomes at short-term follow-up.

Nonarthritic Hip Pathology Patterns According to Sex, Femoroacetabular Impingement Morphology, and Generalized Ligamentous Laxity

BACKGROUND

Sex differences are frequently encountered when diagnosing orthopaedic problems. Current literature suggests specific sex differences, such as a higher prevalence of cam-type femoroacetabular impingement syndrome in male patients and features of hip instability in female patients.

PURPOSE

To identify hip pathology patterns according to sex, alpha angle deformity, and generalized ligamentous laxity (GLL) in a nonarthritic patient population that underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome and labral tears.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Patients who underwent primary hip arthroscopy between February 2008 and February 2017 were included and separated into male and female groups for initial analysis. Patients were excluded if they had Tönnis osteoarthritis grade >1, previous ipsilateral hip surgery, or previous hip conditions. The demographics, radiographic findings, intraoperative findings, and surgical procedures were then analyzed and compared. Subanalyses were performed for both groups. A threshold of 1 SD above the mean alpha angle in the male group was used to create 2 subgroups. For female patients, GLL based on a Beighton score ≥4 was used to divide the group. Intraoperative findings were compared for both subanalyses.

RESULTS

A total of 2701 hips met all inclusion and exclusion criteria. Of those, 994 hips were in the male group and 1707 in the female group. The mean ± SD age was 36.6 ± 13.8 and 37.1 ± 15.0 years for the male and female groups, respectively(P = .6288). The average body mass index was significantly higher in the male group (P < .0001). GLL was more common in women (38.6%) than men (13.6%) (P < .001). The male group had a higher proportion of acetabular Outerbridge grade 3 (21.8%) and 4 (19.2%) lesions when compared with the female group (9.3% and 6.3%, respectively) (P < .0001). Men in the subgroup with an alpha angle ≥78° reported higher rates of acetabular Outerbridge grade 4 damage than men with an alpha angle <78° (P < .001). Mean lateral center-edge angle was lower in the female subgroup with Beighton score ≥4 vs <4 (23.7°± 4.2° vs 31.3°± 5.8°; P < .0001).

CONCLUSION

In this analysis of a large cohort of patients who underwent hip arthroscopy, 2 patterns of hip pathologies were related to sex. On average, male patients had larger alpha angles and increased acetabular chondral damage when compared with their female counterparts. Furthermore, a larger cam-type anatomy was associated with more severe acetabular chondral damage in men. In the female group, the incidence of features of hip instability such as GLL were significantly higher than in the male group.

One Bony Morphology, Two Pathologic Entities: Sex-Based Differences in Patients With Borderline Hip Dysplasia Undergoing Hip Arthroscopy

BACKGROUND

Sex-based differences have been largely uncharacterized for patients with borderline hip dysplasia (BHD) undergoing hip arthroscopy.

PURPOSE

To evaluate for sex-based differences in clinical and pathologic characteristics as well as surgical outcomes in patients with BHD undergoing hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Between January 2011 and December 2018, data were prospectively collected on all patients with BHD undergoing primary hip arthroscopy. Patients were included if they had preoperative and minimum 2-year postoperative scores for the modified Harris Hip Score (mHHS), Non-arthritic Hip Score (NAHS), and visual analog scale for pain. Patients with previous ipsilateral hip conditions or surgery, Tönnis grade >1, lateral center-edge angle <18° or >25°, or workers' compensation status were excluded. Patients were then divided by sex and propensity score matched in a 1:1 ratio for body mass index, age, and Tönnis grade. The rates of patients who achieved the minimal clinically important difference were recorded for the mHHS and NAHS. The rates of achieving the patient acceptable symptomatic state for the mHHS were calculated.

RESULTS

A total of 344 hips met the inclusion criteria, and 317 hips (92%) had adequate follow-up. Propensity score matching created cohorts of 109 male and 109 female patients. Male patients had significantly higher preoperative average alpha angles (69.79° vs 58.17°, P < .001), more often requiring a femoroplasty (97.2% vs 83.5%, P < .001), and had higher rates of complex labral tearing (50.5% vs 33.0%, P < .001). Male patients also had higher rates of grade 3 and 4 acetabular labral articular disruption (62.4% vs 19.3%, P < .001) and higher rates of grade 3 and 4 acetabular cartilage injury (59.6% vs 20.2%, P < .001) requiring a microfracture more frequently (32.1% vs 7.3%, P < .001). Female patients more typically had painful internal snapping requiring iliopsoas fractional lengthening (60.6% vs 32.1%, P < .001). Female patients also underwent capsular plication more regularly to address hip instability (79.8% vs 45.9%, P < .001). Male and female patients showed significant improvements in all outcome scores after surgery (P < .001). Female patients achieved the minimal clinically important difference for the NAHS at higher rates (85.3% vs 71.6%, P = .020).

CONCLUSION

Female and male patients with BHD who underwent hip arthroscopy achieved favorable outcomes but had notably dissimilar pathology. Hence, although they share similar acetabular bony morphology, male and female patients with BHD may represent 2 very different pathologic entities.

Revision Hip Arthroscopy in High-Level Athletes: Minimum 2-Year Outcomes Comparison to a Propensity-Matched Primary Hip Arthroscopy Control Group

BACKGROUND

Outcomes of revision hip arthroscopy in the athletic population have not been well established.

PURPOSE

(1) To report clinical outcomes for high-level athletes undergoing revision hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS) or labral tears and (2) to compare these outcomes against a propensity-matched group of high-level athletes undergoing primary hip arthroscopy.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data for professional, college, and high school athletes were prospectively collected and retrospectively reviewed between January 2012 and October 2018. Patients were included if they underwent revision or primary hip arthroscopy and had preoperative and minimum 2-year patient-reported outcome (PRO) scores for modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score Sports-Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. The findings and outcomes of revision athletes were compared with a propensity-matched control group of high-level athletes undergoing primary hip arthroscopy.

RESULTS

A total of 32 hips (29 patients) undergoing revision hip arthroscopy and 92 hips (88 patients) undergoing primary hip arthroscopy were included in our final analysis with a median follow-up time of 29.5 months (95% CI, 27.2-32.1 months) and 36.5 months (95% CI, 33.5-37.7 months), respectively. Athletes undergoing revision surgery showed significant improvement in all recorded PRO measurements and achieved patient acceptable symptomatic state (PASS) and minimal clinically important difference (MCID) for mHHS at high rates (80.6% and 83.9%, respectively). When compared with a propensity-matched primary control group, patients undergoing revision surgery demonstrated lower preoperative and postoperative scores for mHHS, NAHS, and HOS-SSS, but the magnitude of improvement in functional scores was similar between groups. Athletes undergoing revision surgery achieved PASS for HOS-SSS at lower rates than the control group (P = .005), and they were less likely to attempt to return to sport compared with the control group (62.5% vs 87.0%; P < .01).

CONCLUSION

Revision hip arthroscopy is a viable treatment option to improve PROs in high-level athletes at minimum 2-year follow-up. The study group showed significant improvement in functional scores and a high rate of successful outcomes. They experienced similar magnitude of improvement as that of a propensity-matched control group; however, they achieved lower postoperative PRO scores and attempted to return to sport at lower rates.

Comparing Midterm Outcomes of High-Level Athletes Versus Nonathletes Undergoing Primary Hip Arthroscopy: A Propensity-Matched Comparison With Minimum 5-Year Follow-up

BACKGROUND

High-level athletes (HLAs) have been shown to have better short-term outcomes than nonathletes (NAs) after hip arthroscopy.

PURPOSE

(1) To report midterm outcomes of HLAs after primary hip arthroscopy and (2) to compare their results with a propensity-matched cohort of NA patients.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed between February 2008 and November 2015 for HLAs (professional, college, or high school) who underwent primary hip arthroscopy in the setting of femoroacetabular impingement syndrome (FAIS). HLAs were included if they had preoperative, minimum 2-year, and minimum 5-year follow-up data for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score Sports-Specific Subscale (HOS-SSS). Radiographic and intraoperative findings, surgical procedures, patient-reported outcomes (PROs), patient acceptable symptomatic state (PASS), minimal clinically important difference (MCID), and return to sport were reported. The HLA study group was propensity-matched to a control group of NA patients for comparison.

RESULTS

A total 65 HLA patients (67 hips) were included in the final analysis with mean follow-up time of 74.6 ± 16.7 months. HLAs showed significant improvement in all PROs recorded, achieved high rates of MCID and PASS for mHHS (74.6% and 79.4%, respectively) and HOS-SSS (67.7% and 66.1%, respectively), and returned to sport at high rates (80.4%). When compared with the propensity-matched NA control group, HLAs reported higher baseline but comparable postoperative scores for the mHHS and NAHS. HLA patients achieved MCID and PASS for mHHS at similar rates as NA patients, but the HLA patients achieved PASS for HOS-SSS at higher rates that trended toward statistical significance (66.1% vs 48.4%; P = .07). NA patients underwent revision arthroscopic surgery at similar rates as HLA patients (14.9% vs 9.0%, respectively; P = .424).

CONCLUSION

Primary hip arthroscopy results in favorable midterm outcomes in HLAs. When compared with a propensity-matched NA control group, HLAs demonstrated a tendency toward higher rates of achieving PASS for HOS-SSS but similar arthroscopic revision rates at minimum 5-year follow-up.