Ten-Year Survivorship, Outcomes, and Sports Participation in Athletes After Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Arthroscopic treatment for femoroacetabular impingement yields favourable patient-reported outcomes and method survivorship at 10-year follow-up

PURPOSE

To compare the outcomes of hip arthroscopy for femoroacetabular impingement syndrome (FAIS) preoperatively and at minimum 10-year follow-up using patient-reported outcome measures (PROMs).

METHODS

A total of 128 patients with FAIS were prospectively included. The patients underwent arthroscopic surgery for FAIS between 2011 and 2013 and had a minimum of 10-year follow-up. The International Hip Outcome Tool short version (iHOT-12) was the primary outcome. Secondary outcomes were the Copenhagen Hip and Groin Outcome Score (HAGOS), the European Quality of Life-5 Dimensions Questionnaire (EQ-5D), the European Quality visual analogue scale (EQ VAS), the Hip Sports Activity Scale (HSAS) for physical activity level, the Visual Analogue Scale (VAS) for overall hip function and a single question regarding overall satisfaction with the surgery. The Wilcoxon signed rank test was used to compare pre- and postoperative PROMs.

RESULTS

There was a significant improvement (p < 0.001) of iHOT-12, HAGOS subscales, EQ-5D, EQ VAS and VAS for overall hip function. A total of 83% of the patients were satisfied with their surgery. The survivorship of hip arthroscopy, defined as nonconversion to total hip arthroplasty (THA), at the end of the follow-up period was 77%.

CONCLUSION

Patients undergoing arthroscopic treatment for FAIS reported statistically significant and clinically relevant improved outcomes at 10-year follow-up.

LEVEL OF EVIDENCE

Level IV, case series.

Female Sex Increases Susceptibility for the Negative Impacts of Advanced Age and Obesity on Patient-Reported Functional Outcomes 10 Years after Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome

PURPOSE

This study aims to evaluate patient-reported outcomes (PROs) and reoperation rates in patients undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) over a minimum 10-year follow-up stratified by sex, age, and body mass index (BMI).

METHODS

Primary hip arthroscopies performed for FAIS between 2010 and 2013, with a minimum 10-year follow-up, were reviewed. Procedures consisting of microfracture, or labral debridement without repair, were excluded. Ten-year PROs were assessed using the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Patients were categorized into three groups by age (<30, 30-44, >45 years) and BMI (<25.0, 25.0-29.9, ≥30). Minimum clinically important difference (MCID) was set to half the preoperative standard deviation of the cohort. Reoperation rates and PROs were compared, and regression analysis identified independent predictors of PROs.

RESULTS

At minimum 10-year follow-up (mean: 11.6 [10.0-13.9] years), 59.2% follow-up was achieved, representing 154 hips (141 patients). The cohort had a mean age of 38.5 years, BMI of 24.4, and was 68.2% female. At follow-up, 91.6% of the cohort achieved MCID with a 9.7% re-operation rate. In the middle-aged group, males had higher mHHS (mean, 92.8 vs. 85.2, P = 0.015) and NAHS (mean, 91.6 vs. 83.4, P = 0.008) scores compared to females. In the BMI ≥30 group, males had higher mHHS (mean, 83.3 vs. 66.4, P = 0.030) and NAHS scores (mean, 83.0 vs. 58.5, P = 0.035). Only 72.7% of females with BMI ≥30 achieved MCID for mHHS and NAHS, compared to BMI < 25 (96.6% and 94.9%, respectively) and 25-29.9 (87.5% and 83.3%) (mHHS: P = 0.016; NAHS: P = 0.038). Similarly, 78.8% of females aged ≥ 45 achieved MCID for NAHS, compared to 92.9% of those aged < 30 and 97.1% of those 30-44 (P = 0.040). Multivariable regression identified older age (mHHS: P=0.019; NAHS: P=0.042) and higher BMI (mHHS: P=0.007; NAHS: P<0.001) as independently predictive of worse 10-year PROs.

CONCLUSION

Older age and greater BMI independently predicted poorer long-term functional outcomes after hip arthroscopy for FAIS. Female sex, while not independently predictive, may make patients more susceptible to the negative effects of older age and BMI. No significant association was observed for reoperation rates.

LEVEL OF EVIDENCE

Level IV, retrospective therapeutic case series.

Association Between Global Overcoverage and Long-term Survivorship, Chondrolabral Junction Breakdown, and Reduced Joint Space Width: Minimum 8-Year Follow-up

BACKGROUND

Although previous literature has established the association between femoroacetabular impingement and progressive hip osteoarthritis, there exists a paucity of studies investigating the effects of global acetabular overcoverage on chondral wear and long-term outcomes.

PURPOSE

To compare baseline joint space width (JSW), intraoperative findings, long-term total hip arthroplasty (THA)-free survivorship, patient-reported outcome measures (PROMs), pain levels, and patient satisfaction in patients who underwent hip arthroscopy with global overcoverage (GO) to a matched-control (MC) cohort.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

In this retrospective analysis, the authors queried patients who underwent hip arthroscopy for acetabular labral tears secondary to femoroacetabular impingement. Patients with complete PROMs at a minimum 8-year follow-up, the presence of coxa profunda as indicated by an acetabular wall projecting medial to the ilioischial line, and a lateral center-edge angle >40° were matched 1:1 by sex, age, body mass index, Tönnis grade, and labral treatment to a MC cohort of patients who had normal acetabular coverage. Baseline radiographic and intraoperative findings were compared between cohorts. Collected outcomes include the modified Harris Hip Score, Nonarthritic Hip Score, Lower Extremity Functional Scale score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports Specific Subscale, 33-item International Hip Outcome Tool score, pain levels, patient satisfaction, and conversion to THA.

RESULTS

In total, 38 patients with GO were 1:1 matched to a MC cohort. The GO cohort had significantly decreased baseline JSW at 50° (P = .002) and greater chondrolabral junction breakdown (P = .037). The GO and MC cohorts achieved similar outcomes for all 6 PROMs, rates of conversion to THA, pain levels, and patient satisfaction. Kaplan-Meier survival analysis demonstrated that the patients experienced a similar overall 18-year THA-free survival rate (GO: 71.1% vs MC: 84.2%; P = .101). To isolate the long-term effects of GO on hip arthroscopy outcomes, 6- to 18-year THA-free survivorship was examined, revealing that the GO cohort (-13.1%) experienced a significantly greater decrease compared with the MC cohort (-5.3%) (P = .008).

CONCLUSION

Patients with GO had significantly lower baseline ipsilateral JSW at 50° and greater intraoperative severity of chondrolabral junction breakdown. Furthermore, the GO cohort experienced a significantly greater decrease in long-term THA-free survivorship 6 to 18 years after hip arthroscopy.

Editorial Commentary: Complete Capsular Closure in Hip Arthroscopy Shows Superiority in Expected Value Decision Analysis Compared to Incomplete Capsular Closure

In all aspects of orthopaedic surgery, restoring native patient anatomy has shown improved outcomes in comparison to nonanatomic reconstructions. Particular attention has been paid to the hip capsule, as the complex of the iliofemoral, pubofemoral, and ischiofemoral ligaments, as well as the zona orbicularis and iliocapsularis, all play an essential role in hip stability, mechanics, and maintenance of intra-articular pressures. An anatomic approach toward hip arthroscopy also includes labral repair or reconstruction with preservation of the chondrolabral junction and cam resection. Multiple recent studies have revealed improved patient-reported outcomes at long-term (>10-year) follow-up, as well as reduced revision rates and less progression to total hip replacement with complete capsular repairs compared to incomplete closure or no capsular management following hip arthroscopy. We perform an interportal capsulotomy with labral-sided capsular traction sutures for the central compartment, followed by the T-capsulotomy along the femoral neck with femoral-sided traction sutures for the peripheral compartment. At the end of every case, we ensure an anatomic complete capsular closure of the entire T-capsulotomy using a combination of self-retrieving suture guns and curved self-suture passers, often tying 7 or more sutures.

Cartilage Defects Are Negatively Associated With Long-Term Hip Survivorship Following Contemporary Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 10-Year Follow-Up

PURPOSE

To identify the timing and risk factors associated with secondary surgery following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) at 10-year minimum follow-up.

METHODS

A prospectively collected clinical repository was evaluated for cases of primary hip arthroscopy for FAIS between January 2012 and February 2013 with minimum 10-year follow-up. Patients who underwent secondary surgery were propensity matched 1:4 to patients who did not undergo secondary surgery, controlling for age, sex, and body mass index (BMI). The groups were compared on demographics, radiographs, intraoperative findings, operative procedures, and patient-reported outcomes. A Kaplan-Meier survivorship curve was generated. Among the reoperation-free survivors, minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) achievement were recorded for Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS) subscales, modified Harris Hip Score (mHHS), 12-item international Hip Outcome Tool (iHOT-12), and Visual Analog Scale for Pain (VAS Pain).

RESULTS

Twenty-four reoperation patients (67% female; age 40.1 ± 14.3 years; BMI 27.2 ± 5.5) were matched to 96 reoperation-free patients (62% female; age 37.0 ± 10.8 years; BMI 25.2 ± 4.7, P ≥ .111). Mean follow-up was 10.3 ± 0.2 years. No preoperative demographic differences were found between groups. The reoperation group showed more high-grade cartilage defects on the acetabulum and femoral head (33% vs 8%, P = .004; 29% vs 7%, P = .007). A bimodal distribution of time to reoperation was evidenced independent of the secondary surgery performed. Among the reoperation-free survivors, MCID and PASS achievement was as follows: HOS-ADL (69.1%, 62.1%), HOS-SS (69.9%, 74.4%), mHHS (73.3%, 58.1%), iHOT-12 (n/a, 63.8%), and VAS-Pain (80.2%, 62.6%).

CONCLUSIONS

Patients requiring reoperation following primary hip arthroscopy for FAIS demonstrated more severe cartilage defects and a bimodal distribution of time to reoperation.

LEVEL OF EVIDENCE

Level III, retrospective comparative case series.

Return to Sport Following Arthroscopic Management of Femoroacetabular Impingement: A Systematic Review

Background: Femoroacetabular impingement (FAI) is common. The present systematic review updates the current evidence on return to sport (RTS) in patients who have undergone arthroscopic surgery for FAI in any of its variants (CAM, pincer, or both). Methods: The outcomes of interest were sports-related patient-reported outcome measures (PROMs) and the level and time to RTS. All available clinical studies concerning the RTS following arthroscopic management of FAI were considered. In July 2024, the following databases were accessed following the PRISMA guidelines: Embase, Web of Science, and PubMed. Only studies with a minimum of six months of follow-up were eligible. Results: From 1245 initially identified articles, 43 studies (4103 patients) met the inclusion criteria, in which 32.1% (1317 of 4103 patients) were women. The mean length of follow-up was 33.7 ± 15.8 months. The mean age was 28.1 ± 7.2 years, the mean BMI was 24.7 ± 6.4 kg/m2, and 79.6% ± 27.8% of patients returned to sport at the same or higher level at a mean of 14.3 ± 9.6 months. The mean time away from sports was 8.0 ± 3.3 months. Conclusion: Arthroscopic management for FAI leads to a high rate of RTS, with approximately 80% of patients returning to their preinjury level. Future research should focus on standardised definitions of RTS, sport-specific rehabilitation protocols, and the influence of deformity and procedures on RTS.

Editorial Commentary: Magnetic Resonance Imaging May Underestimate Hip Femoral Version Versus Computed Tomography Scan: Both May Be Optimized Using 3-Dimensional Imaging

Hip arthroscopy has become increasingly popular in the treatment of femoroacetabular impingement syndrome. Careful preoperative planning including evaluation of acetabular and femoral version is necessary to optimize outcomes. Increased femoral anteversion has been associated with microinstability, and conversely, decreased femoral version may predispose to impingement. Computed tomography (CT) is considered the gold standard for femoral version measurements and preoperative planning. However, with recent advancements in technology, magnetic resonance imaging (MRI) has shown comparable measurements to CT imaging. In terms of advantages and disadvantages, CT requires radiation, albeit "low dose." MRI has a longer acquisition time, and movement of the patient may affect image quality and subsequent accuracy. MRI generally underestimates true version, probably as a result of patient positioning. Three-dimensional imaging could resolve this issue and may become the gold standard for both CT and MRI.

Patient Factors Influencing Outcomes at 12-Year Follow-up of Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

Arthroscopic treatment of femoroacetabular impingement has increased in popularity since the early 2000s when it was first described, although only a few midterm follow-up studies have been published.

PURPOSE

To describe the outcomes of patients undergoing hip arthroscopy for femoroacetabular impingement at a mean 12-year follow-up and to determine the risk factors for failure.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

The Non-Arthritic Hip Score (NAHS) and a radiographic evaluation were completed preoperatively and at midterm follow-up. Participants were divided into 2 groups according to their clinical evolution. The success group consisted of patients whose NAHS at the final follow-up was above the established Patient Acceptable Symptom State (PASS) threshold of 81.9, whereas patients who underwent a second surgical intervention or did not reach the PASS threshold at final follow-up were assigned to the failure group. These groups were compared to identify preoperative differences in demographic, pathological, and surgical factors.

RESULTS

A total of 95 hips were included, after 23 were lost to follow-up (80.5% follow-up). At a mean follow-up of 12.1 years (range, 9.2-16.0 years), 9 hips required total hip arthroplasty (9.5%), 5 required revision hip arthroscopy (5.3%), 29 did not achieve the NAHS PASS threshold (30.5%), and 52 achieved the NAHS PASS threshold (54.7%). The mean NAHS was 82.4 at final follow-up compared with 66.9 preoperatively (mean difference = 15.5; P < .001). Higher mean body mass index (24.9 vs 23.0; P = .030), older age (30.0 vs 27.2; P = .035), and inferior preoperative lateral joint space width (3.9 vs 4.4; P = .019) were associated with inferior prognosis in the failure group versus success group. Osteoarthritis progression was observed in 69.2% of the failure group and in 34.8% of the success group (P = .082). Labral ossification was observed in 78.3% of all patients, and its lateral projection length was statistically associated with failure (P = .015).

CONCLUSION

At a mean 12-year follow-up, hip arthroscopy for femoroacetabular impingement led to significant clinical improvement, with 55% PASS achievement. In total, 31% of patients were below the PASS threshold, 5% had revision arthroscopy, and only 9% had conversion to total hip arthroplasty for a 45% global failure rate. Increased body mass index, older age, and smaller preoperative lateral joint space width were significant negative prognostic factors. Postoperative degenerative changes were highly prevalent and demonstrated association with failure.

Postoperative hip bracing reduces kinesiophobia in patients undergoing hip arthroscopy: a randomized-controlled trial

INTRODUCTION

Detailed postoperative rehabilitation protocols after hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are still a matter of debate. Adjunctive hip bracing represents a promising tool to improve early patients' mobilization. To present, the effect of hip brace therapy on postoperative functional outcomes and specific patient individual psychologic factors remains controversially discussed. Consequently, we aimed to report postoperative outcomes focusing on hip function, pain and kinesiophobia between braced and unbraced patients.

MATERIALS AND METHODS

A prospective, randomized-controlled trial was conducted, including patients undergoing hip arthroscopy for FAIS. After exclusion, a final study cohort of 36 patients in the intervention group (postoperative hip brace) and 36 patients in the control group (no hip brace) were compared for kinesiophobia (Tampa Scale of Kinesiophobia), pain (Visual analog scale) and joint function (International Hip Outcome Tool-12) within the first six postoperative months.

RESULTS

Hip arthroscopy significantly improved all patient-reported outcomes in both groups. Intergroup analysis revealed significantly lower levels of kinesiophobia in braced patients at 6-months follow up (30.7 vs. 34.1, p = 0.04) while not negatively affecting pain and joint function. No intra- and postoperative complications occurred within both groups.

CONCLUSIONS

This study could demonstrate that bracing after hip arthroscopy can positively influence kinesiophobia, while the brace did not negatively impact postoperative pain and quality of life. Thus, hip bracing could be a viable assistive therapy in the postoperative rehabilitation phase after hip arthroscopy.

Editorial Commentary: Extreme Hip Labral Size (Both Small and Large) Shows Inferior Outcomes After Arthroscopic Labral Repair With Femoroacetabular Impingement Treatment

Arthroscopic management of hip femoroacetabular impingement shows reliable improvement in pain and patient-reported outcomes, high survivorship, and low conversion to total hip arthroplasty, particularly in the absence of dysplasia. Concomitant labral repair-or augmentation versus reconstruction when indicated- consistently shows better results than labral debridement. The effect of labral size on outcomes has been studies in several series. Some studies show that smaller labra show inferior outcomes after repair, others show labral size makes no difference in outcomes, and one showed that patients large labra actually had worse outcomes. Perhaps labral size at either extreme does worse. Labral size is likely to remain one of many factors worth evaluating when prognosticating repair outcomes or indicating when advanced reconstructive options are warranted.

Outcomes of Flexibility Sport Athletes With Borderline Hip Dysplasia After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: A Propensity-Matched Analysis at Minimum 2-Year Follow-up

BACKGROUND

Hip arthroscopy has proved successful in treating femoroacetabular impingement syndrome (FAIS) in patients with and without borderline hip dysplasia (BHD). Despite a high prevalence of BHD in patients who participate in sports with high flexibility requirements, a paucity of literature evaluates the efficacy of hip arthroscopy in treating FAIS in flexibility sport athletes with BHD.

PURPOSE

To compare minimum 2-year patient-reported outcomes (PROs) and achievement of clinically significant outcomes in flexibility sport athletes with BHD undergoing primary hip arthroscopy for FAIS with capsular plication with results in flexibility sport athletes without dysplasia.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were prospectively collected for patients undergoing primary hip arthroscopy for FAIS with BHD, defined as a lateral center-edge angle of 18° to 25°, who reported participation in a sport with a high flexibility requirement, including dance, gymnastics, figure skating, yoga, cheerleading, and martial arts, according to previous literature. These patients were matched 1:2 to flexibility sport athletes without dysplasia, controlling for age, sex, and body mass index. Preoperative and minimum 2-year postoperative PROs were collected and compared between groups. Cohort-specific minimal clinically important difference and patient acceptable symptom state achievement was compared between groups.

RESULTS

In total, 52 flexibility sport athletes with BHD were matched to 104 flexibility sport athletes without BHD. Both groups showed similar sport participation (P = .874) and a similar level of competition (P = .877). Preoperative lateral center-edge angle (22.2°± 1.6° vs 31.5°± 3.9°; P < .001) and Tönnis angle (10.9°± 3.7° vs 5.8°± 4.4°; P < .001) differed between groups. Capsular plication was performed in all cases. Both groups achieved significant improvement in all PROs (P < .001) with no differences in postoperative PROs between groups (P≥ .147). High minimal clinically important difference (BHD group: 95.7%; control group: 94.8%) and patient acceptable symptom state (BHD group: 71.7%; control group: 72.2%) achievement for any PRO was observed with no differences between groups (P≥ .835).

CONCLUSION

Flexibility sport athletes with BHD achieved similar outcomes as those of flexibility sport athletes without BHD after hip arthroscopy for FAIS with capsular plication.