Revision Surgery and Progression to Total Hip Arthroplasty After Surgical Correction of Femoroacetabular Impingement: A Systematic Review

Delayed hip arthroscopy for femoroacetabular impingement syndrome does not increase revision but does increase rates of chronic opiate use

Introduction

In recent years, the utilization of hip arthroscopy to treat femoroacetabular impingement syndrome (FAIS) has increased due to its low complication rates, positive impact on patient-reported outcomes (PROs), and association with faster rehabilitation. Despite this, there are high rates of revision and conversion to total hip arthroplasty (THA) in some of these patients. It is unclear whether time from initial FAIS diagnosis to surgery is a risk factor for poor outcomes. In this study, we examined the relationship between timing of hip arthroscopy for FAIS and rates of 2-year revision hip procedures, 2-year conversion to total hip arthroplasty (THA), post-operative medical complications, and opioid prescriptions.

Methods

This is a retrospective cohort study utilizing the PearlDiver database. Current Procedural Terminology (CPT) and International Classification of Diseases (ICD) codes were used to identify patients who had surgery for FAIS with minimum 2 years follow-up available. Patients were stratified by 3-month intervals into 5 groups based on time from diagnosis of FAIS to hip arthroscopy. Multivariate logistic regression was performed to determine factors independently associated with continued opiate use and subsequent surgeries.

Results

A total of 14,677 patients were included in the study. The 2-year rate of revision hip arthroscopy was 4.2%. As time from diagnosis to surgery increased, even in multivariate regression analysis, there was a higher risk of filling an opioid prescription 90 days after surgery (P < 0.001). Regression analysis demonstrated that timing of surgery was not associated with 2-year revision hip arthroscopy or conversion to THA. Age, sex, obesity, and tobacco use were significant predictors of revision hip arthroscopy and conversion to THA (p < 0.001).

Conclusion

There is no significant difference between timing of surgery for FAIS and odds of revision or conversion to THA. Prolonged opiate use after hip arthroscopy was significantly higher as duration from initial FAIS diagnosis to surgery increased. Age, sex, obesity, and tobacco use are significant predictors for revision, conversion to THA, and continued opiate prescriptions.

Long-term Outcomes of Primary Hip Arthroscopy: Multicenter Analysis at Minimum 10-Year Follow-up With Attention to Labral and Capsular Management

BACKGROUND

Hip arthroscopy is rapidly advancing, with positive published outcomes at short- and midterm follow-up; however, available long-term data remain limited.

PURPOSE

To evaluate outcomes of primary hip arthroscopy at a minimum 10-year follow-up at 2 academic centers by describing patient-reported outcomes and determining reoperation and total hip arthroplasty (THA) rates.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients with primary hip arthroscopy performed between January 1988 and April 2013 at 2 academic centers were evaluated for postoperative patient-reported outcomes-including the visual analog scale, Tegner Activity Scale score, Hip Outcome Score Activities of Daily Living and Sport Specific subscales, modified Harris Hip Score, Nonarthritic Hip Score, 12-item International Hip Outcome Tool, surgery satisfaction, and reoperations.

RESULTS

A total of 294 patients undergoing primary hip arthroscopy (age, 40 ± 14 years; 66% women; body mass index, 27 ± 6) were followed for 12 ± 3 years (range, 10-24 years) postoperatively. Labral debridement and repair were performed in 41% and 59% of patients, respectively. Of all patients who underwent interportal capsulotomy, 2% were extended to a T-capsulotomy, and 11% underwent capsular repair. At final follow-up, patients reported a mean visual analog scale at rest of 2 ± 2 and with use of 3 ± 3, a 12-item International Hip Outcome Tool of 68 ± 27, a Nonarthritic Hip Score of 81 ± 18, a modified Harris Hip Score of 79 ± 17, and a Hip Outcome Score Activities of Daily Living of 82 ± 19 and Sport Specific subscale of 74 ± 25. The mean surgical satisfaction was 8.4 ± 2.4 on a 10-point scale, with 10 representing the highest level of satisfaction. In total, 96 hips (33%) underwent reoperation-including 65 hips (22%) converting to THA. THA risk factors included older age, higher body mass index, lower lateral center-edge angle, larger alpha angle, higher preoperative Tönnis grade, as well as labral debridement and capsular nonrepair (P≤ .039). Patients undergoing combined labral and capsular repair demonstrated a THA conversion rate of 3% compared with 31% for patients undergoing combined labral debridement and capsular nonrepair (P = .006). Labral repair trended toward increased 10-year THA-free survival (84% vs 77%; P = .085), while capsular repair demonstrated significantly increased 10-year THA-free survival (97% vs 79%; P = .033).

CONCLUSION

At a minimum 10-year follow-up, patients undergoing primary hip arthroscopy demonstrated high satisfaction and acceptable outcome scores. In total, 33% of patients underwent reoperation-including 22% who underwent THA. Conversion to THA was associated with patient factors including older age, higher Tönnis grade, and potentially modifiable surgical factors such as labral debridement and capsular nonrepair.

Patients Undergoing Revision Hip Arthroscopy Demonstrate Comparable Survivability and Improvement but Worse Postoperative Outcomes Compared to Patients Undergoing Primary Hip Arthroscopy: A Propensity Matched Study at Five-Year Follow-Up

PURPOSE

To compare mid-term clinical outcomes between patients undergoing primary hip arthroscopy (HA) versus revision hip arthroscopy (RHA) for femoroacetabular impingement syndrome (FAIS).

METHODS

A retrospective cohort study was conducted on 1,862 patients who underwent hip arthroscopy for FAIS from January 2012 to April 2017. Patients who underwent RHA were propensity matched in a 1:4 ratio by age, sex, body mass index (BMI), and exercise status to patients who underwent primary HA. Preoperative and postoperative radiographs were assessed. Patient-reported outcomes before and at 5 years after surgery, including the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and Visual Analog Scale (VAS) for Pain and Satisfaction, were compared between groups. Minimally clinically important difference and patient-acceptable symptomatic state (PASS) achievement rates were compared using previously published thresholds.

RESULTS

Fifty-one patients who underwent RHA (35 female, 16 male; age 36.2 ± 10.2 years; BMI 26.5 ± 5.9) were followed up for 63.9 ± 9.2 months and then propensity matched in a 1:4 ratio by sex, age, and BMI to 204 control patients who underwent primary HA. At midterm follow-up, patients in the RHA cohort had significantly lower scores for HOS-SS (RHA 64.9 ± 32.5 vs HA 75.3 ± 26.2, P = .044), mHHS (RHA 72.2 ± 22.4 vs HA 80.1 ± 18.1, P = .039), and iHOT-12 (RHA 61.4 ± 29.3 vs HA 71 ± 27.6, P = .043) compared to primary HA patients. Rates of achieving PASS were significantly decreased for HOS-SS (RHA 38.3% vs HA 55.4%, P = .039) and iHOT-12 (RHA 41.9% vs HA 59.9%, P = .035) in the RHA cohort. There were no significant differences in rates of conversion to THA or subsequent reoperation on the index hip between groups.

CONCLUSIONS

Patients undergoing revision hip arthroscopy demonstrate comparable survivability and magnitude of improvement but may experience worse overall outcome scores and meet thresholds for clinically significant outcomes less often when compared to primary hip arthroscopy patients.

LEVEL OF EVIDENCE

Level III; retrospective comparative study.

Defining Thresholds and Predictors for Achieving the Patient Acceptable Symptom State for Patient-Reported Outcome Measures After Revision Hip Arthroscopy

BACKGROUND

The Patient Acceptable Symptom State (PASS) after primary hip arthroscopy has been determined; nonetheless, the PASS still needs to be defined for revision hip arthroscopy.

PURPOSE

To define minimum 2-year follow-up PASS thresholds for the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), visual analog scale (VAS) for pain, and International Hip Outcome Tool-12 (iHOT-12) after revision hip arthroscopy, and to identify predictors of achieving the PASS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included if they had baseline and minimum 2-year follow-up scores for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12. PASS was calculated using the anchor-based method. Receiver operating characteristic curve analysis was used to determine the thresholds for the PASS. A multivariate logistic regression was used to identify predictors for achieving the PASS.

RESULTS

A total of 318 patients who underwent revision hip arthroscopy met the inclusion criteria. Of those patients, 292 (91.8%) had baseline and minimum 2-year follow-up. Of this group, 68 patients (72.1% female and 27.9% male; mean age, 32.9 years) answered the PASS anchor question. Achievement PASS rates were 58.8%, 41.2%, 52.9%, 60.3%, and 52.9% for the mHHS, NAHS, HOS-SSS, VAS, and iHOT-12, respectively. The area under the curve (AUC) values for the PASS for mHHS, NAHS, HOS-SSS, VAS, and iHOT-12 were 0.912, 0.888, 0.857, 0.903, and 0.871, respectively, indicating excellent discrimination. The PASS for the mHHS was 76 (sensitivity, 0.809; specificity, 0.905), for the NAHS was 86.3 (sensitivity, 0.660; specificity, 1), for the HOS-SSS was 64.3 (sensitivity, 0.745; specificity, 0.905), for the VAS was 3 (sensitivity, 0.830; specificity, 0.905), and for the iHOT-12 was 64.3 (sensitivity, 0.745; specificity, 0.905). Body mass index (BMI) was identified as a significant predictor of achieving PASS for the NAHS (OR, 0.967; 95% CI, 0.940-0.996; P = .027), as patients with a BMI ≤25.4 had 1.03 times higher odds ratio of achieving PASS for the NAHS.

CONCLUSION

After revision hip arthroscopy, the minimum 2-year follow-up PASS thresholds for the mHHS, NAHS, HOS-SSS, VAS for pain, and iHOT-12 were 76, 86.3, 64.3, 3, and 64.3, respectively. The odds ratio of achieving PASS for the NAHS was 1.03 times higher for patients with a BMI ≤25.4.

Risk factors for liner wear and head migration in total hip arthroplasty: a systematic review

Total hip arthroplasty (THA) is a successful orthopaedic surgical procedure, and its longevity depends on bearing components and implant fixation. Optimizing polyethylene and ceramics has led to improved wear parameters and contributed to improved long-term outcomes. The present systematic review investigated whether time span from implantation, patient characteristics and performance status exert an influence on liner wear and head migration in THA. This study was conducted in conformity to the 2020 PRISMA guidelines. All the clinical investigations which reported quantitative data on the amount of liner wear and head migration in THA were considered. Only studies which reported quantitative data at least on one of the following patient characteristics were suitable: mean age, mean BMI (kg/m2), sex, side, time span between the index THA and the last follow-up (months) were eligible. A multiple linear model regression analysis was employed to verify the association between patient characteristics and the amount of liner wear and/or head migration. The Pearson Product-Moment Correlation Coefficient was used to assess the association between variables. Data from 12,629 patients were considered. The mean length of the follow-up was 90.5 ± 50.9 months. The mean age of patients at surgery was 58.4 ± 9.4 years, and the mean BMI was 27.2 ± 2.5 kg/m2. 57% (7199 of 12,629 patients) were women, and in 44% (5557 of 12,629 patients) THAs were performed on the left. The mean pre-operative Harris hip score was 46.5 ± 6.0 points. There was evidence of a moderate positive association between the amount of liner wear and the time elapsed between the index surgery to the follow-up (P = 0.02). There was evidence of a moderate positive association between the amount of head migration and the time elapsed between the index surgery to the follow-up (P = 0.01). No further statistically significant association was found. The time elapsed between the index surgery to the follow-up was the most important factor which influence the head migration and liner wear in THA. Patients' characteristics and preoperative physical activity did not influence the amount of head migration and liner wear.

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

Background

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

Methods

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

Results

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

Conclusion

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

Level of evidence

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

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

Purpose

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

Method

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

Result

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

Conclusion

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