Self-reported Mental Disorders Negatively Influence Surgical Outcomes After Arthroscopic Treatment of Femoroacetabular Impingement

The critical importance of recognition, evaluation, and management of mental health on outcomes following hip arthroscopy - A synthetic narrative review: Current concepts

Mental health and wellness influence patients with hip pain and dysfunction secondary to Femoroacetabular Impingement Syndrome, acetabular dysplasia, and labral injury. Disorders of mental wellness may impact hip preservation surgery patients both before and after surgery. Major depression and generalized anxiety are the two most common diagnoses that affect hip preservation surgery patients. There are dozens of unique questionnaires that can subjectively and objectively characterize the mental health of patients with hip pain. Pain threshold and pain tolerance are two issues that must be recognized to optimally predict treatment outcome in an informed consent shared decision-making discussion. Patient expectations may also significantly influence preoperative symptoms and postoperative outcome. Pain threshold, pain tolerance, and patient expectations are entities traditionally viewed as qualitative and unmeasurable. However, many valid and reliable methods exist to quantitatively assess these patient-specific variables. Recent original research and synthetic review publications have consistently concluded similar findings: patients with disorders of mental wellness generally have lower preoperative patient-reported outcome scores, do improve following surgery, albeit to a lesser magnitude than non-mental disorder patients, and ultimately have lower postoperative scores at their final follow. As with most orthopaedic surgery literature, the investigation of mental health and hip preservation is primarily via retrospective level four evidence with small numbers of patients from a single centre and single surgeon at short-term follow-up. Although hip preservation surgeons are orthopaedic surgeons by training and practice, they must be able to recognize mental wellness disorders and either treat or refer when suspected or identified.

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

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

Association Between Symptoms of Anxiety and Depression, Hip Pathology, and Patient-Reported Outcomes After Hip Arthroscopy for Femoroacetabular Impingement

BACKGROUND

In patients with femoroacetabular impingement (FAI), mental health has been implicated in both symptom severity and postoperative outcomes. However, there are limited data regarding the independent influences of baseline mental health and hip pathology on patient-reported outcomes over time after hip arthroscopy.

PURPOSE

To evaluate the association between mental health and structural hip pathology with pain, hip function, and quality of life (QOL).

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patient records from a single surgeon's hip outcomes registry were retrospectively reviewed. Mental health was evaluated using the Patient-Reported Outcomes Measurement Information System Anxiety and Depression scores. Pain was evaluated with the Single Assessment Numeric Evaluation score for Activities of Daily Living (SANE-ADL), while hip-related QOL was evaluated with the 12-item International Hip Outcome Tool (iHOT-12). Hip function was assessed with the Hip Outcome Score (HOS) Sport-Specific (SS) and ADL subscales. Separate mixed models were used to predict pain, QOL, and hip function, including hip pathology measures (size of labral tear, grade of chondral damage, preoperative alpha angle), anxiety, depression, and time as fixed effects and individuals as a random effect.

RESULTS

A total of 312 patients were included in this study. The preoperative alpha angle, degree of intraoperative cartilage damage, and size of the labral tear were not associated with pain or QOL (P > .05 for all). However, higher levels of anxiety and depression were significantly associated with lower SANE-ADL scores (estimate ± SE) (anxiety: -0.59 ± 0.07, P < .0001; depression: -0.64 ± 0.08, P < .0001), iHOT-12 scores (anxiety: -0.72 ± 0.07, P < .0001; depression: -0.72 ± 0.08, P < .0001), HOS-SS scores (anxiety: -0.68 ± 0.09, P < .0001; depression: -0.57 ± 0.10, P < .0001), and HOS-ADL scores (anxiety: -0.43 ± 0.05, P < .0001; depression: -0.43 ± 0.06, P < .0001).

CONCLUSION

Patients had similar improvements in pain scores, QOL, and hip function after hip arthroscopy for FAI irrespective of their degree of hip pathology. Additionally, preoperative symptoms of anxiety and depression symptoms were associated with greater pain, decreased QOL, and worse hip function both pre- and postoperatively, independent of the degree of hip pathology. This suggests that efforts to directly address symptoms of anxiety and depression may improve outcomes after hip arthroscopy.

Effects of Preexisting Anxiety and Depression on Postoperative Outcomes in Patients Aged 30 Years and Younger Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome

Background: Mental health influences postoperative outcomes in orthopedic procedures. Increasing attention is being paid to this effect. Purpose: We sought to evaluate the effect of diagnosed depression, anxiety, or both on postoperative outcomes in patients who have undergone hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Methods: We conducted a retrospective cohort study of 289 patients aged 30 years or younger who underwent hip arthroscopy for FAIS at a single institution from January 2014 to June 2021. Univariate statistics were used to assess differences between patients diagnosed with depression, anxiety, or both, and those without these diagnoses. Differences included demographics, operative characteristics, and postoperative outcomes: duration of postanesthesia care unit (PACU) stay, PACU pain scores, complications, reoperations, postoperative injections, 90-day emergency department (ED) visits, and patient-reported outcome measures (PROMs). Multivariate analysis was used to evaluate risk factors for postoperative complications, including wound infection, documented reinjury, postoperative intra-articular hip injection, and any reoperation. Results: Patients diagnosed with depression, anxiety, or both were more likely to be older, female, and have a higher comorbidity burden. At the time of surgery, they were more likely to undergo concomitant procedures, including bursectomy and iliotibial band release. Postoperatively, they had longer PACU stays (90.5 vs 75.1 minutes) and higher first PACU pain scores (5.9 vs 4.6), as well as higher rates of postoperative injection (18.1 vs 9.2%), any reoperation (13.9% vs 4.6%), and revision hip arthroscopy (11.1% vs. 3.7%). Diagnoses of depression, anxiety, or both were independently predictive of any reoperation (odds ratio [OR] = 2.841) and revision hip arthroscopy (OR = 3.401). Conclusion: This retrospective cohort study found that, in patients undergoing hip arthroscopy for FAIS, there was an association between a diagnosis of depression, anxiety, or both, and increased comorbidities, higher first PACU pain scores, longer PACU stays, and increased rates of postoperative injection, any reoperation, or revision hip arthroscopy. Targeted interventions may improve outcomes, but further study is warranted.

The Influence of Psychosocial Factors on Hip Surgical Disorders and Outcomes After Hip Arthroscopy: A Systematic Review

PURPOSE

To systematically review the associations between mental health and preoperative or postoperative outcomes of hip arthroscopy for femoroacetabular impingement.

METHODS

The literature search was conducted using the PubMed, EMBASE and PsychINFO databases following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

RESULTS

Nine studies were identified that met the inclusion and exclusion criteria. All studies assessing patient-reported outcomes found significantly lower patient-reported outcomes (modified Harris Hip Score, Hip Outcome Score-Activities of Daily Living, Hip Outcome Score-Sports-Specific Subscale, and International Hip Outcome Tool scores) related to worse mental health functioning before surgery. Specifically, preoperative Hip Outcome Score-Activities of Daily Living and Hip Outcome Score-Sports-Specific Subscale were significantly greater in control patients than patients in the mental health group by 11.6 points (mean difference; 95% confidence interval 7.58-15.79, P < .001) and 10 points (95% confidence interval 5.14-14.87, P < .001), without significant heterogeneity between studies (I² = 28.59, P = .25; I² = 0, P = .93), respectively. Patients with lower mental health status also had lower rates of achieving a minimal clinically important difference in 5 studies included in this review.

CONCLUSIONS

This systematic review finds consistent evidence supporting the association between negative psychological function and worse preoperative and postoperative outcomes for patients with hip disorders. Understanding both the effect of mental health on surgical outcomes and the potential benefits of psychological intervention may represent an opportunity to improve patient outcomes following hip arthroscopy.

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III.

Low Back Pain, Psychiatric Disorders, and a Combination of Both Negatively Affect Hip Arthroscopy Outcomes in Servicemembers

BACKGROUND

Hip arthroscopy for femoroacetabular impingement (FAI) in athletes, including military servicemembers, has resulted in variable outcomes. The prevalence of low back pain (LBP) and psychiatric disorders (PSYs) is high among patients undergoing hip arthroscopy.

PURPOSE

To determine the effect of LBP, PSYs, and the combination of both on outcomes in servicemembers treated arthroscopically for FAI.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

Between April 2016 and June 2020, a total of 108 consecutive active-duty servicemembers underwent hip arthroscopy by a single surgeon at a single military medical center. Servicemembers were grouped according to the presence of preoperative LBP (Group LBP), a PSY (Group PSY), or both (Group Both), and outcomes were compared with those of servicemembers without these comorbidities (Group None). The minimum follow-up was 6 months. The primary outcome measure was return to duty (RTD). Secondary outcomes included the Nonarthritic Hip Score (NAHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL) subscale, and Hip Outcome Score-Sports (HOS-S) subscale.

RESULTS

All servicemembers' final duty status was confirmed, with a mean follow-up of 2 years (range, 6 months-4.3 years). The prevalence of preoperative LBP and PSY was 27% and 39%, respectively. RTD was 59% (10/17) in Group LBP, 10% (3/30) in Group PSY, 0% (0/12) in Group Both, and 47% (23/49) in Group None. Compared with Group None, the risk of discontinuing military service was statistically higher in Group PSY (relative risk [RR], 1.70 [95% CI, 1.41-1.99]) and Group Both (RR, 1.88 [95% CI, 1.62-2.15]) but not in Group LBP (RR, 0.78 [95% CI, 0.15-1.40]). The mean preoperative secondary outcomes all significantly improved postoperatively in Group None (NAHS, 58 to 75 [P < .001]; HOS-ADL, 63 to 74 [P < .001]; HOS-S, 44 to 57 [P < .001]). Among the comorbid groups, the mean HOS-S did not significantly improve (Group LBP, 45 to 48 [P = .71]; Group PSY, 36 to 44 [P = .22]; Group Both 43 to 45 [P = .75]), and <50% of these servicemembers achieved HOS-S meaningful clinical benefit metrics.

CONCLUSION

Preoperative LBP, PSY, and a combination of both negatively affected outcomes after hip arthroscopy. Preoperative counseling is crucial in setting realistic outcome expectations.

Editorial Commentary: It's "90% Mental": Mental Distress Influences Symptom Perception in Hip Arthroscopy

There is a well-established relationship between mental distress, mental health disorders, and the perception of pain and physical dysfunction. While determining the root cause is often challenging, increasing levels of mental distress are associated with increasingly disruptive manifestation of physical symptoms and vice versa. In femoroacetabular impingement syndrome, patients with preoperative mental distress exhibit more impactful levels of symptoms. Patients do show symptomatic improvement with appropriate surgical management, even in the presence of mental distress. Patients and surgeons should recognize both the physical and mental contributions to pain perception when developing a treatment plan for musculoskeletal pathologies and incorporate this as part of the postoperative rehabilitation process.

Patients Obtain Meaningful Clinical Benefit After Hip Arthroscopy Despite Preoperative Psychological Distress: A Propensity-Matched Analysis of Mid-Term Outcomes

PURPOSE

To evaluate the influence of baseline psychological distress on patient-reported outcomes (PROs) after arthroscopic hip surgery for femoroacetabular impingement at a minimum of 5 years.

METHODS

Demographic and intraoperative data were prospectively collected from patients who underwent primary arthroscopic hip surgery for femoroacetabular impingement and labral tears after failure of conservative management between June 2012 and December 2014. Included patients had preoperative and minimum 5-year postoperative PROs and visual analog scale scores for pain and satisfaction. The 12-item Short Form Health Survey (SF-12) Mental Component Summary (MCS) score was used to stratify patients into 2 cohorts: Patients with an average or above-average score (SF-12 MCS score ≥ 50) were considered psychologically non-distressed, whereas those who scored below average (SF-12 MCS score < 50) were considered to have psychological distress. Distressed patients were propensity matched by age, sex, and body mass index to an equal number of non-distressed patients.

RESULTS

Of the 153 hips that met the inclusion criteria, 117 (76.5%) had minimum 5-year follow-up. Eighty-two hips were included in the final analysis after propensity matching, with 41 in both the distressed and non-distressed cohorts. Preoperatively, patients in the distressed cohort reported inferior scores for all PROs. There was a significant difference in the SF-12 MCS score between groups at 2 years, but similar scores were observed for all other PROs. At minimum 5-year follow-up, there were no differences between groups for any PRO. There were no differences in the rates of achieving the minimal clinically important difference for all PROs or in achieving the patient acceptable symptomatic state for the modified Harris Hip Score.

CONCLUSIONS

Patients with baseline psychological distress may have a lower functional status at the time of presentation but still gain meaningful clinical benefit and pain improvement from arthroscopic hip surgery, with mid-term outcomes comparable to those obtained by patients without preoperative psychological distress.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Mood Disorders Are Associated with Increased Perioperative Opioid Usage and Health Care Costs in Patients Undergoing Knee Cartilage Restoration Procedure

OBJECTIVE

To identify the prevalence of mood disorder diagnoses in patients undergoing cartilage transplantation procedures and determine the relationship between mood disorders, opioid usage, and postoperative health care costs.

DESIGN

Patients with current procedural terminology (CPT) codes for osteochondral autograft transplantation (OAT), osteochondral allograft transplantation (OCA), and autologous chondrocyte implantation (ACI) were identified in the Truven Health Marketscan database (January 2009-September 2014). Patients were grouped based on having a preoperative mood disorder diagnosis (preMDD). Preoperative opioids, postoperative opioids ≥90 days, and health care costs within the year postoperative were compared for those with and without mood disorders. Costs were analyzed, adjusting for preoperative cost, sex, age, and opioid usage, for those with and without mood disorders.

RESULTS

A total of 3,682 patients were analyzed (ACI: 690, OAT: 1,294, OCA: 1,698). A quarter of patients had preMDD (ACI: 25.4%, OAT: 20.6%, OCA: 22.7%). Postoperative opioid use was more prevalent in preMDD patients (OAT: 37.1% vs. 24.1%, P < 0.001; OCA: 30.4% vs. 24.8%, P = 0.032; ACI: 33.7% vs. 26.2%, P = 0.070) (odds ratio [OR] ranged from 1.29 to 1.86). First-year postoperative log-transformed costs were significantly greater for preMDD patients (ACI: $7,733 vs. $5,689*, P = 0.012; OAT: $5,221 vs. $3,823*, P < 0.001; OCA: $6,973 vs. $3,992*, P < 0.001; *medians reported). The estimated adjusted first postoperative year cost increase for preMDD OCA patients was 41.7% (P < 0.001) and 28.0% for OAT patients (P = 0.034). There was no statistical difference for ACI patients (P = 0.654).

CONCLUSION

Cartilage transplantation patients have a high prevalence of preoperative mood disorders. Opioid use and health care costs were significantly greater for patients with preoperative mood disorder diagnoses.

LEVEL OF EVIDENCE

Level III, retrospective therapeutic study.

Preoperative Psychosocial Factors and Short-term Pain and Functional Recovery After Hip Arthroscopy for Femoroacetabular Impingement Syndrome

CONTEXT

Low mental health scores, depression, and anxiety are associated with worse pain and functional outcomes after hip arthroscopy for patients with femoroacetabular impingement syndrome (FAIS). Preoperative screening of psychosocial factors such as self-efficacy, kinesiophobia, and pain catastrophizing may further aid in identifying patients at risk for poorer outcomes.

OBJECTIVE

To compare preoperative function and psychosocial factors between patients with and those without elevated postoperative pain 3 months after hip arthroscopy for FAIS.

DESIGN

Prospective cohort study.

SETTING

University health center.

PATIENTS OR OTHER PARTICIPANTS

Fifty-one individuals with FAIS (41 women, 10 men; age = 37.6 ± 12.3 years, body mass index = 27.1 ± 4.1 kg/m2).

MAIN OUTCOME MEASURE(S)

Preoperatively, participants completed the Pain Self-Efficacy Questionnaire (PSEQ), Tampa Scale for Kinesiophobia (TSK), Pain Catastrophizing Scale (PCS), 12-Item International Hip Outcome Tool (iHOT-12), and a 10-point visual analog scale (VAS) for hip pain at rest and during activity. Three months postoperatively, they completed the PSEQ, TSK, PCS, iHOT-12, and VAS. Preoperative scores were compared between those with (VAS ≥ 3) and those without (VAS < 3) elevated postoperative pain using Mann-Whitney U tests, and odds ratios were calculated to determine the odds of having elevated postoperative pain and lower postoperative function.

RESULTS

Participants with elevated postoperative pain at rest and during activity had worse preoperative psychosocial health (P ≤ .04). Those with elevated postoperative pain at rest had worse preoperative function (P < .001). The odds of having elevated postoperative pain at rest were 45 times and 4.5 times higher for those with low self-efficacy and high pain catastrophizing, respectively (P values ≤ .03). The odds of having elevated postoperative pain during activity were 7.1, 6.2, and 3.5 times higher for those with low self-efficacy, high kinesiophobia, and high pain catastrophizing, respectively (P values ≤ .04). The odds of having lower postoperative iHOT-12 scores were 7.5 and 14.0 times higher for those with high kinesiophobia and pain catastrophizing, respectively (P values ≤ .03).

CONCLUSIONS

Poor preoperative psychosocial health increased the odds of elevated pain and worse function 3 months after hip arthroscopy for FAIS. This is a first step in identifying the psychosocial factors that may contribute to poorer long-term hip arthroscopy outcomes.

Association Between Comorbid Depression and Rates of Postoperative Complications, Readmissions, and Revision Arthroscopic Procedures After Elective Hip Arthroscopy

Background:

Depression and related psychiatric diagnoses are common in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). The effects of depression on postoperative complications, readmissions, and additional ipsilateral hip surgery are not well studied.

Hypothesis:

Patients with preoperative depression who undergo hip arthroscopy for FAIS would experience higher rates of 90-day postoperative complications and readmissions, with an increased risk of additional ipsilateral hip procedures, as compared with patients without depression.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

A retrospective cohort study between 2010 and 2019 was performed using the Mariner/PearlDiver database. Current Procedural Terminology and International Classification of Diseases codes were used to compare patients with and without preexisting depression who underwent hip arthroscopy for FAIS. Patients were matched at a 1:1 ratio based on age, sex, Charlson Comorbidity Index, body mass index, and tobacco use. Patients undergoing shoulder or knee arthroscopy were also identified to compare lifetime preoperative depression prevalence amongst groups.

Results:

The lifetime preoperative depression prevalence was significantly higher in patients undergoing hip arthroscopy as compared with patients undergoing shoulder or knee arthroscopy (25.4% vs 22.2% vs 19.8%; P < .001). When compared with the patients without depression, patients with preoperative depression had higher rates of 90-day readmissions (2.4% vs 1.5%) and complications, including urinary tract infection (36.2% vs 28.9%), pneumonia (12.9% vs 9.1%), hematoma formation (3.1% vs 1.9%), acute kidney injury (4.0% vs 2.6%), deep venous thrombosis/pulmonary embolism (2.6% vs 1.7%), and superficial infection (4.9% vs 2.8%; P < .01 for all comparisons). Preoperative depression was associated with significantly higher odds of undergoing revision hip arthroscopy within 2 years (6.3% vs 2.4%; P < .001).

Conclusion:

Patients with preexisting depression experienced higher rates of 90-day postoperative complications and hospital readmissions after elective hip arthroscopy for FAIS and were more likely to undergo revision hip arthroscopy within 2 years of the index procedure.

Effect of Baseline Mental Health on 1-Year Outcomes After Hip Arthroscopy: A Prospective Cohort Study

Background:

Patient factors, including mental health, sex, and smoking, have been found to be more predictive of preoperative hip pain and function than intra-articular findings during hip arthroscopy for femoroacetabular impingement (FAI); however, little is known about how these factors may influence patients’ postoperative outcomes.

Hypothesis:

We hypothesized that lower patient-reported mental health scores would be significant risk factors for worse patient-reported outcomes (PROs) 1 year after arthroscopic hip surgery for FAI and that baseline intra-articular pathology would fail to demonstrate an association with outcomes 1 year after FAI surgery.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

A prospective cohort of patients undergoing hip arthroscopy for FAI were electronically enrolled. Baseline and 1-year follow-up PROs were collected, including Hip disability and Osteoarthritis Outcome Score for pain (HOOS-Pain), HOOS–Physical Function Short Form (HOOS-PS), and Veterans RAND 12-Item Health Survey–Mental Component Score (VR-12 MCS). Intra-articular operative findings and treatment were documented at the time of surgery. Proportional odds logistic regression models were built for 1-year outcomes (HOOS-Pain, HOOS-PS, and VR-12 MCS). Risk factors included patient characteristics and intraoperative anatomic and pathologic findings.

Results:

Overall, 494 patients underwent hip arthroscopy for FAI, and 385 (78%) were evaluated at 1 year with at least 1 PRO. The median patient age was 33 years, mean body mass index was 25.5 kg/m², and 72% were female. Multivariable analysis demonstrated that better baseline HOOS-Pain, HOOS-PS, and VR-12 MCS were significantly associated with improvement in the 1-year scores for each PRO. Higher VR-12 MCS was significantly associated with better 1-year HOOS-Pain and HOOS-PS, while current and former smokers had worse 1-year outcomes than those who never smoked. In ranking each variable’s relative importance, baseline HOOS-Pain and HOOS-PS and baseline VR-12 MCS were identified as the strongest predictors of 1-year HOOS-Pain and HOOS-PS in our multivariable model.

Conclusion:

During hip arthroscopy for FAI, patient factors, including baseline hip pain and function, mental health, and smoking, were independently associated with 1-year PROs of hip pain and function, while intra-articular pathology such as the presence of labral tear and its treatment, tear size, tear location, and anchors placed were not independently associated.

Pain Catastrophizing and Kinesiophobia Affect Return to Sport in Patients Undergoing Hip Arthroscopy for the Treatment of Femoroacetabular Impingement

Purpose

To assess whether pain catastrophizing and kinesiophobia affect return to sport (RTS) or clinically significant outcome (CSO) achievement in patients undergoing hip arthroscopy for the treatment of femoroacetabular impingement (FAI).

Methods

Patients undergoing primary hip arthroscopy at a single institution between January 2017 and March 2017 were prospectively enrolled. Patients received the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS) questionnaires preoperatively, 3 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively. Patients also received the Hip Outcome Score Sport-Specific (HOS-SS) questionnaire preoperatively and 1 year and 2 years' postoperatively. An RTS questionnaire was completed at final follow-up. Bivariate correlations were conducted between PCS and TSK-11 scores and RTS status and achievement of CSOs of HOS-SS, based on patient acceptable symptom state (PASS) and substantial clinical benefit (SCB).

Results

Fifty-eight patients with an average age of 31.9 ± 12.2 and body mass index of 24.0 ± 3.8 participated in sport prior to surgery and were included in the study. Forty-two (72.4%) patients returned to sport at 10.5 ± 7.1 months following surgery. There was a significant reduction in TSK-11 and PCS scores at 1-year follow-up (TSK-11, 26.1 ± 6.0 vs 18.6 ± 6.1, P < .001; PCS, 17.7 ± 10.5 vs 4.3 ± 6.8, P < .001) as well as a significant improvement in HOS-SS (P < .001). At 1 year, fair correlations were demonstrated between PCS (r = -0.446, P = .010) and TSK (r = -0.330, P = .029) scores and RTS. Patient who returned to sport had lower PCS (8.5 ± 11.7 vs 3.0 ± 3.7, P = .010) and TSK-11 (21.8 ± 8.5 vs 17.6 ± 4.8, P = .029) scores at 1 year. At 1-year follow-up, PCS (r = -0.572, P = .001) and TSK-11 (r = -0.441, P = .012) scores demonstrated fair correlations with achieving PASS for HOS-SS at 2-year follow-up.

Conclusions

Patient kinesiophobia and pain catastrophizing at 1-year follow-up were negatively correlated with RTS and achievement of a CSO in sport-related activities at 2-year follow-up.

Level of Evidence

III, prospective cohort study.

Improving Surgical Quality for Patients with Mental Health Illnesses: A Narrative Review

OBJECTIVE

To establish and define disparities in care for patients presenting with surgical disease who have pre-existing mental health diagnoses.

SUMMARY BACKGROUND DATA

Mental illness affects approximately 6.7 million Canadians. For them, stigma, comorbid disorders, and sequelae of psychiatric diagnoses can be barriers patients face to receive equitable healthcare. The goal of this review is to define inequities in surgical care for patients with pre-existing mental illness.

METHODS

We search OVID Medline, Pubmed, EMBASE, and the Cochrane review files using a combination of search terms using a PICO (population, intervention, comparison, outcome) model focusing on surgical care for patients with mental illness.

RESULTS

The literature on mental illness in surgical patients focused primarily on preoperative and postoperative disparities in surgical care between patients with and without a diagnosis of mental illness. Preoperatively, patients were 7.5-40% less likely to be deemed surgical candidates, were less likely to receive testing, and were more likely to present at later stages of their disease or have delayed surgical care. Similar themes arose in the postoperative period: patients with mental illness were more likely to require ICU admission, were up to 3 times more likely to have a prolonged length of hospital stay, had a 14-270% increased likelihood of having postoperative complications, and had significantly higher healthcare costs.

CONCLUSIONS

Surgical patients with preexisting psychiatric diagnoses have a propensity for worse perioperative outcomes compared to patients without reported mental illness. Taking a thorough psychiatric history can potentially help surgical teams address disparities and access to care as well as anticipate and prevent adverse outcomes.

Editorial Commentary: Personalized Hip Arthroscopy Outcome Prediction Using Machine Learning-The Future Is Here

Machine learning and artificial intelligence are increasingly used in modern health care, including arthroscopic and related surgery. Multiple high-quality, Level I evidence, randomized, controlled investigations have recently shown the ability of hip arthroscopy to successfully treat femoroacetabular impingement syndrome and labral tears. Contemporary hip preservation practice strives to continually refine and improve the value of care provision. Multiple single-center and multicenter prospective registries continue to grow as part of both United States-based and international hip preservation-specific networks and collaborations. The ability to predict postoperative patient-reported outcomes preoperatively holds great promise with machine learning. Machine learning requires massive amounts of data, which can easily be generated from electronic medical records and both patient- and clinician-generated questionnaires. On top of text-based data, imaging (e.g., plain radiographs, computed tomography, and magnetic resonance imaging) can be rapidly interpreted and used in both clinical practice and research. Formidable computational power is also required, using different advanced statistical methods and algorithms to generate models with the ability to predict individual patient outcomes. Efficient integration of machine learning into hip arthroscopy practice can reduce physicians' "busywork" of data collection and analysis. This can only improve the value of the patient experience, because surgeons have more time for shared decision making, with empathy, compassion, and humanity counterintuitively returning to medicine.

Effect of marital status on patient-reported outcomes following total hip arthroplasty: a matched analysis with minimum 2-year follow-up

INTRODUCTION

Mental health and patient expectation have been identified as key predictors of recovery following THA; however, there is limited literature examining the effects of social support and marital status on patient-reported outcomes (PROs).

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent THA between July 2008 and January 2016. Patients were included if they underwent primary THA during this period and if they had documented preoperative marital status of married, divorced, or never married. Married patients were group matched to non-married patients (divorced or never married) with similar sex, age, body mass index (BMI), gender distribution, and frequency of surgical approach.

RESULTS

There were 414 married patients and 98 non-married patients who were eligible and had minimum 2-year follow-up. Mean PROs were significantly worse in the non-married group than the married group for the following measures: modified Harris Hip Score (p = 0.002), Harris Hip Score (p = 0.002), Forgotten Joint Score (p = 0.04), and the physical portions of the Veterans RAND (p = 0.025) and Short Form (p = 0.02) surveys.

CONCLUSIONS

Our study demonstrated inferior absolute PRO scores at latest follow-up for patients who were non-married compared to married following THA. These results show that while total hip replacement may still yield clinical benefit in all patients, non-married patients may ultimately achieve an inferior functional status, and expectations should be adjusted accordingly. Physicians should assess levels of psychosocial support in their patients prior to undergoing hip arthroplasty in order to optimise results.

Development and Internal Validation of Supervised Machine Learning Algorithms for Predicting Clinically Significant Functional Improvement in a Mixed Population of Primary Hip Arthroscopy

PURPOSE

To (1) develop and validate a machine learning algorithm to predict clinically significant functional improvements after hip arthroscopy for femoroacetabular impingement syndrome and to (2) develop a digital application capable of providing patients with individual risk profiles to determine their propensity to gain clinically significant improvements in function.

METHODS

A retrospective review of consecutive hip arthroscopy patients who underwent cam/pincer correction, labral preservation, and capsular closure between January 2012 and 2017 from 1 large academic and 3 community hospitals operated on by a single high-volume hip arthroscopist was performed. The primary outcome was the minimal clinically important difference (MCID) for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) at 2 years postoperatively, which was calculated using a distribution-based method. A total of 21 demographic, radiographic, and patient-reported outcome measures were considered as potential covariates. An 80:20 random split was used to create training and testing sets from the patient cohort. Five supervised machine learning algorithms were developed using 3 iterations of 10-fold cross-validation on the training set and assessed by discrimination, calibration, Brier score, and decision curve analysis on an independent testing set of patients.

RESULTS

A total of 818 patients with a median (interquartile range) age of 32.0 (22.0-42.0) and 69.2% female were included, of whom 74.3% achieved the MCID for the HOS-ADL. The best-performing algorithm was the stochastic gradient boosting model (c-statistic = 0.84, calibration intercept = 0.20, calibration slope = 0.83, and Brier score = 0.13). Of the initial 21 candidate variables, the 8 most important features for predicting the MCID for the HOS-ADL included in model training were body mass index, age, preoperative HOS-ADL score, preoperative pain level, sex, Tönnis grade, symptom duration, and drug allergies. The algorithm was subsequently transformed into a digital application using local explanations to provide customized risk assessment: https://orthoapps.shinyapps.io/HPRG_ADL/.

CONCLUSIONS

The stochastic boosting gradient model conferred excellent predictive ability for propensity to gain clinically significant improvements in function after hip arthroscopy. An open-access digital application was created, which may augment shared decision-making and allow for preoperative risk stratification. External validation of this model is warranted to confirm the performance of these algorithms, as the generalizability is currently unknown.

LEVEL OF EVIDENCE

IV, Case series.

Evaluation of outcome reporting trends for femoroacetabular impingement syndrome- a systematic review

PURPOSE

The aim of this systematic review was to evaluate the trends in the literature regarding surgical treatment for femoroacetabular impingement syndrome (FAIS) and to present which patient-reported outcome-measures (PROMs) and surgical approaches are included.

METHODS

This systematic review was conducted with the PRISMA guidelines. The literature search was performed on PubMed and Embase, covering studies from 1999 to 2020. Inclusion criteria were clinical studies with surgical treatment for FAIS, the use of PROMs as evaluation tool and studies in English. Exclusion criteria were studies with patients < 18 years, cohorts with < 8 patients, studies with primarily purpose to evaluate other diagnoses than FAIS and studies with radiographs as only outcomes without using PROMs. Data extracted were author, year, surgical intervention, type of study, level of evidence, demographics of included patients, and PROMs.

RESULTS

The initial search yielded 2,559 studies, of which 196 were included. There was an increase of 2,043% in the number of studies from the first to the last five years (2004-2008)-(2016-2020). There were 135 (69%) retrospective, 55 (28%) prospective and 6 (3%) Randomized Controlled Trials. Level of evidence ranged from I-IV where Level III was most common (44%). More than half of the studies (58%) originated from USA. Arthroscopic surgery was the most common surgical treatment (85%). Mean follow-up was 27.0 months (± 17 SD), (range 1.5-120 months). Between 1-10 PROMs were included, and the modified Harris Hip Score (mHHS) was most commonly used (61%).

CONCLUSION

There has been a continuous increase in the number of published studies regarding FAIS with the majority evaluating arthroscopic surgery. The mHHS remains being the most commonly used PROM.

Machine Learning Algorithms Predict Clinically Significant Improvements in Satisfaction After Hip Arthroscopy

PURPOSE

To develop machine learning algorithms to predict failure to achieve clinically significant satisfaction after hip arthroscopy.

METHODS

We queried a clinical repository for consecutive primary hip arthroscopy patients treated between January 2012 and January 2017. Five supervised machine learning algorithms were developed in a training set of patients and internally validated in an independent testing set of patients by discrimination, Brier score, calibration, and decision-curve analysis. The minimal clinically important difference (MCID) for the visual analog scale (VAS) score for satisfaction was derived by an anchor-based method and used as the primary outcome.

RESULTS

A total of 935 patients were included, of whom 148 (15.8%) did not achieve the MCID for the VAS satisfaction score at a minimum of 2 years postoperatively. The best-performing algorithm was the neural network model (C statistic, 0.94; calibration intercept, -0.43; calibration slope, 0.94; and Brier score, 0.050). The 5 most important features to predict failure to achieve the MCID for the VAS satisfaction score were history of anxiety or depression, lateral center-edge angle, preoperative symptom duration exceeding 2 years, presence of 1 or more drug allergies, and Workers' Compensation.

CONCLUSIONS

Supervised machine learning algorithms conferred excellent discrimination and performance for predicting clinically significant satisfaction after hip arthroscopy, although this analysis was performed in a single population of patients. External validation is required to confirm the performance of these algorithms.

LEVEL OF EVIDENCE

Level III, therapeutic case-control study.

Chronic Hip Injury Has a Negative Emotional Impact on the Male Athlete With Femoroacetabular Impingement

PURPOSE

To evaluate the impact of hip arthroscopy for femoroacetabular impingement (FAI) on both the physical and mental components of the 36-Item Short Form (SF-36) and assess how changes in health status compare with improvements in physical function and ability to continue to play (CTP) 2 years after surgery.

METHOD

Data collected prospectively from male athletes undergoing primary arthroscopic correction of FAI between November 2008 and October 2016 were analyzed. Physical (PCS) and mental (MCS) component scores of the SF-36 were assessed preoperatively and 2 years postoperatively. The minimal clinical important difference (MCID) was calculated using an anchor-based percentage of possible improvement technique, and the proportion of athletes achieving MCID was established. Logistic regression analysis was used to identify predictors of achieving MCID. CTP was assessed at 2-year follow-up.

RESULTS

486 cases were included, age 25.9 ± 5.6 years. Median PCS improved from baseline 69.4 (51.9 to 85.0) to 91.9 (81.9 to 97.5) at 2 years (P < .001). Median MCS remained unchanged-preoperative, 88 (76 to 92); postoperative, 88 (80 to 96)-although the difference in the distribution of scores was statistically significant (P < .001). Calculated MCID was 60.1% (PCS) and 58.1% (MCS). Mean improvement was significantly higher for PCS compared with MCS (17.4 versus 3.7, P < .001) The proportion of cases achieving MCID was 56.9% and 28.7% for PCS and MCS, respectively, and the difference was statistically significant (P < .001). Lower Tonnis grade (odds ratio [OR] 0.601, 95% confidence interval [CI] 0.377 to 0.958; P = .032) and symptom duration <2 years (OR 0.624, 95% CI 0.406 to 0.960; P = .032) were predictive of achieving PCS MCID. Higher preoperative scores decreased the odds of achieving MCID (OR 0.965, 95% CI 0.955 to 0.975; P < .001; OR 0.972, 95% CI 0.958 to 0.986; P < .001 for PCS and MCS, respectively). 77.3% continued to play their main preinjury sport. Where CTP was not achieved, a significantly higher proportion of cases failed to meet MCID for the MCS compared with PCS (85% versus 60%, P < .001).

CONCLUSION

Arthroscopic management of sports-related FAI results in excellent overall clinical outcome and high levels of satisfaction and CTP at 2 years. Chronic hip injury has a significant negative effect on the physical and mental well-being of athletes; corrective surgery may restore physical function but is more limited in its ability to improve mental health status in this athletic cohort.

LEVEL OF EVIDENCE

IV, therapeutic case series.

Treatment of Labral Calcification in the Setting of Femoroacetabular Impingement Syndrome With Arthroscopic Calcification Excision, Labral Repair, and Osteoplasty Improves Outcomes

PURPOSE

To describe the diagnosis and 2-year outcomes of arthroscopic treatment for labral calcification in the setting of femoroacetabular impingement syndrome (FAIS).

METHODS

A retrospective analysis was performed from a prospectively collected database of patients with FAIS undergoing hip arthroscopy. Patients with FAIS with labral calcification were differentiated radiographically from patients with other paralabral radiopaque densities such as os acetabuli, acetabular rim fractures, and labral ossification. Patients with FAIS with labral calcification were treated with arthroscopic calcification excision, labral repair, and osteoplasty and matched by age, sex, and body mass index with a cohort of patients with FAIS without labral calcifications who underwent labral repair and osteoplasty. Pre- and 2 years postoperatively, patients completed patient-reported outcome (PRO) scores including the modified Harris Hip Score, Hip disability and Osteoarthritis Outcome Score (HOOS), 12-item Short-Form survey, and visual analog scale.

RESULTS

In total, 40 hips (21 male, 19 female) with FAIS and labral calcification were included (age 36.8 ± 8.1, body mass index, 25.9 ± 4.5). Patients with FAIS with labral calcification demonstrated similar significant PRO score improvements compared with a matched cohort of patients with FAIS without labral calcification at 2 years after surgery (visual analog scale: (-)2.3 ± 0.4, (-)2.7 ± 0.5, modified Harris Hip Score: 16.1 ± 2.6, 17.1 ± 3.2; HOOS symptoms: 21.9 ± 3.7, 18.6 ± 3.6; HOOS pain: 22.1 ± 3.0, 25.0 ± 3.5; HOOS activities of daily living: 20.2 ± 2.8, 23.8 ± 3.3; HOOS sport: 35.6 ± 5.0, 35.6 ± 4.1; HOOS quality of life: 36.9 ± 4.5, 37.5 ± 4.4; 12-item Short-Form survey physical component summary: 15.5 ± 2.3, 20.1 ± 2.1, respectively). Both cohorts achieved minimal clinically important differences at equivalent rates (60%-82.5%) for all PRO scores.

CONCLUSIONS

Patients with labral calcification in the setting of FAIS can be effectively treated with arthroscopic calcification excision, labral repair, and osteoplasty. These patients demonstrate significant improvements in patient-reported outcomes and achievement of minimal clinically important differences at 2 years similar to patients undergoing arthroscopic treatment for FAIS without labral calcification.

LEVEL OF EVIDENCE

Level III, matched cohort study.

Influence of mental health on postoperative outcomes in patients following biceps tenodesis

PURPOSE

To evaluate the relationship between preoperative mental health measured by the Short-Form 12 health survey mental component score and outcomes after isolated biceps tenodesis.

METHODS

The American Shoulder and Elbow Surgeons form (ASES), Single Assessment Numeric Evaluation (SANE), Constant-Murley score (CMS), and visual analog scale (VAS) for pain were administered preoperatively and at 6 and 12 months postoperatively to consecutive patients undergoing isolated biceps tenodesis between 2014 and 2018. Minimal clinically important difference, substantial clinical benefit (SCB), patient-acceptable symptom state (PASS), and rates of achievement were calculated. Patients were stratified by mental health status based on preoperative scores on the Short-Form 12 health survey mental component score. Multivariate logistic regression was performed to evaluate preoperative mental health status on achievement of minimal clinically important difference, SCB, and PASS.

RESULTS

Patients demonstrated significant improvements in all outcome measures (P < .001). Patients with depression reported inferior postoperative scores on all patient-reported outcome measures. Low preoperative mental health score significantly predicted reduced likelihood to achieve SCB (odds ratio [OR]: 0.38, 95% confidence interval [CI]: 0.17-0.81, P = .01) and PASS (OR: 0.28, 95% CI: 0.12-0.65, P = .003) on the ASES form, SANE (OR: 0.24, 95% CI: 0.10-0.61, P = .003), CMS (OR: 0.25, 95% CI: 0.08-0.77, P = .016), and VAS pain (OR: 0.01, 95% CI: 0.00-0.31, P = .008).

CONCLUSION

Patients with depression reported inferior scores on all postoperative patient-reported outcome measures and demonstrated lower odds of achieving the SCB and PASS on the ASES form and PASS on the SANE, CMS, and VAS pain, compared with nondepressed patients.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis

BACKGROUND

Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia.

PURPOSE

To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models.

RESULTS

We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; P < .001), and they reported worse postoperative PROM scores compared with nonimpaired patients (weighted mean difference, -20.2 points; 95% CI, -32.9 to -7.5; P < .001).

CONCLUSION

Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor.

REGISTRATION

CRD42019124836 (PROSPERO).

The impact of mental health disorders on outcomes following hip arthroscopy for femoroacetabular impingement syndrome: a systematic review

Hip arthroscopy for femoroacetabular impingement syndrome (FAI) has been shown to be beneficial in the short- to medium-term though outcomes vary between individuals. Multiple factors have been suggested to affect outcomes including pre-operative mental health disorders. We undertook a systematic review to assess the evidence relating to the effect of pre-existing mental health disorders on the outcomes following hip arthroscopy for FAI. Following PRISMA guidelines, a multi-database search was undertaken using three key concepts: 'mental health', 'FAI' and 'hip arthroscopy'. Results were screened and data extracted from relevant studies. A total of six studies met the inclusion criteria including 2248 hips, all published between 2017 and 2019. All studies were of evidence level III or IV with reasonable methodological quality. One study demonstrated pre-operative depression to be related to altered pain reduction in the short-term following surgery. Three studies reported inferior outcomes in the medium-term (1-2 years) in those with worse mental health. One study demonstrated an increased risk of persistent pain 2 years following surgery and one a reduced chance of returning to active military service following surgery in those with worse mental health. Despite inferior outcomes individuals with mental health disorders did still benefit from surgery in general. In conclusion, the presence of pre-existing poor mental health is associated with inferior outcomes in the medium-term following arthroscopic surgery for FAI. Surgeons should consider screening patients for mental health disorders before surgery and counselling them appropriately as to the potential for less satisfactory surgical outcomes.

Editorial Commentary: Hip Preservation and Opioids

Approximately one-third of patients undergoing arthroscopic hip preservation surgery for femoroacetabular impingement syndrome and labral tears are on preoperative opioid medications. The single most important predictor for prolonged chronic postoperative opioid use is preoperative use. Despite the well-documented high success rates in nonarthritic, nondysplastic individuals undergoing hip arthroscopy, up to half of those individuals on preoperative opioids may still be on opioids at 1 to 2 years of follow-up. Mental wellness disorders (e.g., depression, anxiety, substance abuse) significantly impact both pre- and postoperative pain, function, and activity in nearly all joint and general health outcome measures. Multimodal pain management strategies have shown excellent reduction in perioperative opioid utilization. Intraoperative techniques should strive for comprehensive true hip preservation: labral repair, accurate cam/pincer morphology correction, and routine capsular management. Objective, quantitative pain threshold and pain tolerance measurements may improve treatment decision-making, with better prediction of surgical outcomes. Future personalized health care may use a single individual's mu opioid receptor (OPRM-1 gene) and a number of other genetic markers for pain management to reduce the need for traditional opioid medications. Is opioid-free hip arthroscopy possible? Absolutely. Will the opioid epidemic end? Yes, but we have a lot of work to do.

Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database

PURPOSE

To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety.

METHODS

Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy.

RESULTS

Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001).

CONCLUSIONS

Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic study.

What is the Role of Kinesiophobia and Pain Catastrophizing in Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome?

Purpose

To (1) investigate trends in kinesiophobia and pain catastrophizing after hip arthroscopy for femoroacetabular impingement syndrome (FAIS), and (2) determine whether kinesiophobia and pain catastrophizing scores are associated with achieving minimal clinically important difference (MCID) for any of the hip-specific patient-reported outcome questionnaires.

Methods

Patients undergoing primary hip arthroscopy for treatment of FAIS between December 2016 and March 2017 were prospectively enrolled. Patients received the Tampa Scale of Kinesiophoibia-11 (TSK-11) and Pain Catastrophizing Scale (PCS) questionnaires preoperatively, 6 months, and 1 year postoperatively. They also received the hip-specific patient-reported outcome questionnaires (Hip Outcome Score Activities of Daily Living and Sport-Specific subscales, modified Harris Hip Score, and International Hip Outcome Tool-12), as well as visual analog scale for satisfaction and pain preoperatively and 1-year postoperatively. The threshold for achieving MCID was determined for each hip outcome tool, and patients achieving MCID were compared with those who did not.

Results

A total of 85 (80.2%) patients (mean age: 33.7 ± 12.4 years; female: 75.3%) were included in the final analysis. At 1-year follow-up, there was a significant reduction in TSK-11 scores (26.22 ± 5.99 to 18.70 ± 6.49; P < .001) and PCS scores (17.81 ± 10.13 to 4.77 ± 7.57; P < .001) when compared with preoperative scores. 1-year PCS scores were significantly lower in patients achieving MCID compared with patients failing to achieve MCID (3.2 ± 4.4 vs 10.8 ± 15.2; P = .006). There were no significant differences in TSK-11 scores between those achieving and not achieving MCID.

Conclusions

Patient kinesiophobia and pain catastrophizing both show significant improvements 1 year after undergoing hip arthroscopy for FAIS. However, pain catastrophizing scores at 1 year are significantly greater in patients not achieving MCID, whereas no association was identified between kinesiophobia and likelihood for MCID achievement. This suggests PCS may be a more useful tool than TSK-11 during postoperative rehabilitation for identifying patients at risk for not achieving MCID.

Level of Evidence

Level II, prospective case series.

Is the Actual Failure Rate of Hip Arthroscopy Higher Than Most Published Series? An Analysis of a Private Insurance Database

BACKGROUND

The use of hip arthroscopy (HA) for the management of intra-articular hip pathology has increased greatly, with a 600% increase in utilization from 2006-2010. Studies have demonstrated good to excellent outcomes in patients undergoing hip arthroscopy for treatment of femoroacetabular impingement (FAI) syndrome. However, some patients undergoing primary hip arthroscopy will require revision hip arthroscopy (revision HA) or conversion to total hip arthroplasty (THA). The purpose of the present study was to evaluate the association between hip arthroscopy failure and (1) osteoarthritis, (2) age > 40 years, and (3) psychiatric comorbidities.

METHODS

The Humana Inc. insurance claims database was used to identify patients undergoing hip arthroscopy between 2007 and 2015, with query by CPT (current procedural terminology code) of more than 25 million deidentified insurance and Medicare beneficiary claims. Following primary hip arthroscopy, patients were longitudinally tracked for subsequent ipsilateral hip arthroscopy (revision HA) or total hip arthroplasty (THA) with a minimum of 1-year clinical follow-up from the primary HA procedure. Hip arthroscopy failure (HA failure) was defined specifically as patients who underwent a revision HA or THA with a minimum of 1-year of clinical follow-up from the primary HA procedure. Variables assessed included presence of pre-existing osteoarthritis, age < 40 years or age > 40 years, and presence of preoperatively diagnosed psychiatric comorbidities including depression or anxiety. The relationships between revision HA, THA, or HA failure and these variables were assessed utilizing univariate and multiple logistic regression analysis. Independent predictors of revision ipsilateral hip arthroscopy and subsequent hip arthroplasty were identified using multiple logistic regression.

RESULTS

In total, 785 patients (64.1% female) underwent primary hip arthroscopy. The overall failure rate with a minimum of 1-year clinical follow-up from the index HA procedure was 18%[140/785; 8% (63/785) revision hip arthroscopy, 10% (82/785) THA]. Multivariable logistic regression analysis identified psychiatric comorbidities (Odds Ratio [OR] 2.8, 95% Confidence Interval [CI] 1.2-6.2, p<0.01) as the only independent predictor of hip arthroscopy failure (revision HA or THA). Independent predictors of revision HA included both psychiatric comorbidity (OR 2.8, 95% CI 1.2-6.2, p<0.01) and age < 40 years (OR 2.6, 95% CI 1.4-5.0, p<0.01), while age > 40 years (OR 3.09, 1.47-7.25, p<0.005), smoking (OR 2.05, 95% CI, 1.68-1.88, p=0.02), and osteoarthritis (OR 3.24, 95% CI 1.98-5.43, p<0.001) predicted conversion to THA.

CONCLUSION

The hip arthroscopy failure rate of 18% in the present study is alarmingly high, a figure much higher than reported in previously published series. Patient factors associated with conversion to THA included age > 40 years, smoking, and preexisting osteoarthritis. The presence of psychiatric comorbidities, specifically depression and anxiety, was independently associated with revision HA and overall HA failure.Level of Evidence: III.

Do psychological factors or radiographic severity play a role in the age of onset in symptomatic developmental dysplasia of hip and femoroacetabular impingement syndrome?

Background

Age of onset in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement syndrome (FAIS) varies. The purpose of this study was to investigate whether psychological factors, radiographic, and clinical variables were related to age of onset of hip pain in DDH and FAIS.

Methods

We collected demographic, clinical, and radiographic data on 56 DDH and 84 FAIS patients. Each was diagnosed based on radiographic findings and clinical history. Age of onset was operationalized by subtracting patient reported duration of symptoms from patient age at presentation. Pain catastrophizing (PCS) and depression were assessed with the pain catastrophizing scale and hospital anxiety and depression scale (HADS), respectively. Multiple linear regression modeling, with Lasso variable selection, was implemented.

Results

Pain catastrophizing, anxiety, and depression were not significantly related to age of DDH onset (p-values > 0.27) or age of FAIS onset (p-values > 0.29). LASSO-penalized linear regression revealed alpha Dunn angle, Tonnis grade, prior hip surgery, WOMAC pain score, and iHOT total score were associated with age of onset in FAIS (Adjusted R² = 0.3099). Lateral center edge angle (LCEA), alpha frog angle, Tonnis grade, SF12 physical functioning, and body mass index (BMI) were associated with age of DDH onset (Adjusted R² = 0.3578).

Conclusions

Psychological factors, as measured by PCS and HADS, were not associated with age of onset in DDH or FAIS. Functional impairment as measured by WOMAC pain and impaired active lifestyle as measured by iHOT were found to affect age of FAIS onset. For DDH, impaired physical functioning and increasing BMI were found to be associated with age of onset. Severity of the disease, as measured radiographically by LCEA and alpha Dunn angle, was also found to be associated with earlier age of onset in DDH and FAIS, respectively. A patient’s radiographic severity may have more of a relationship to the onset of pain than physiologic factors.

Early Hip Arthroscopy for Femoroacetabular Impingement Syndrome Provides Superior Outcomes When Compared With Delaying Surgical Treatment Beyond 6 Months

BACKGROUND

There is literature on the association between chronic preoperative pain and worse outcomes among patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). However, there are few data on whether there is an optimum window that provides the best midterm surgical outcomes.

PURPOSE

To assess the outcomes of hip arthroscopy for FAIS according to timing of surgical intervention.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients undergoing arthroscopic intervention for FAIS with a minimum 2-year follow-up were included. All patients completed the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport Specific (HOS-SS), modified Harris Hip Score (mHHS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scales for pain and satisfaction. Patients were stratified by preoperative symptom duration. We compared 3 to 6 months of symptoms with other subsequent time frames (>6-12, >12-24, and >24 months). Clinically significant outcome was determined with the minimal clinically important difference and patient acceptable symptomatic state.

RESULTS

A total of 1049 patients were included (mean ± SD: age, 32.3 ± 12.4 years; follow-up, 30.8 ± 6.7 months). Patients undergoing surgery at 3 to 6 months of symptoms had no significant differences in outcome when compared with those in the >6- to 12-month group except for the iHOT-12 (P = .028). Patients with symptom duration of >12 to 24 months and >24 months had worse outcomes across all measures (P < .001). Surgery within 3 to 6 months of symptoms was predictive for achieving the minimal clinically important difference on the HOS-ADL (odds ratio [OR], 1.81; 95% CI, 1.20-2.73) and HOS-SS (OR, 1.90; 95% CI, 1.11-3.17), as well as the patient acceptable symptomatic state on the HOS-ADL (OR, 1.85; 95% CI, 1.34-2.56) and HOS-SS (OR, 1.58; 95% CI, 1.14-2.18), when compared with the other groups. In multivariate regression analysis, symptom duration was predictive of visual analog scale for pain (β = 3.10; 95% CI, 1.56-4.63; P < .001) and satisfaction (β = -4.16; 95% CI, -6.14 to -2.18; P < .001).

CONCLUSION

Among patients with FAIS, surgical intervention early after the onset of symptoms (3-6 months) was associated with superior postoperative outcomes when compared with patients who underwent surgical intervention beyond this time frame. This information may help guide preoperative decision making regarding delay of surgery. These findings should be confirmed in a prospective study.

Do Female Athletes Return to Sports After Hip Preservation Surgery for Femoroacetabular Impingement Syndrome?: A Comparative Analysis

Background

Female patients undergoing surgery for femoroacetabular impingement syndrome (FAIS) often experience inferior clinical outcomes and higher failure rates when compared with male patients. The influence of athletic status on hip arthroscopic outcomes in female patients, however, is unclear.

Purpose

To compare patient-reported outcomes (PROs) of athletic and nonathletic female patients undergoing hip arthroscopic surgery for FAIS, and to determine the return-to-sports rate in the athlete group.

Study Design

Cohort study; Level of evidence, 3.

Methods

Two-year PROs were assessed in female patients who had undergone hip arthroscopic surgery for FAIS by a single surgeon. Patients who self-identified as athletes were compared with nonathletes. Preoperative and postoperative PRO scores including the Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sport-Specific (HOS-SS), modified Harris Hip Score (mHHS), and visual analog scale (VAS) for pain and satisfaction were analyzed and compared between athletes and nonathletes. Subanalysis was performed based on patient age and body mass index (BMI).

Results

A total of 330 female patients undergoing hip arthroscopic surgery for FAIS were identified. Of these, 221 patients identified as athletes (mean age, 29.1 ± 11.1 years; mean BMI, 23.0 ± 3.5 kg/m²) and 109 as nonathletes (mean age, 39.3 ± 11.4 years; mean BMI, 27.8 ± 5.8 kg/m²). Both groups demonstrated improvements in HOS-ADL, HOS-SS, mHHS, VAS for pain, and VAS for satisfaction scores (P < .001 for all). Athletes had significantly higher postoperative PRO scores compared with nonathletes (P < .001 for all). A 1:1 matched-pair subanalysis of 97 athletes and 97 nonathletes controlling for age and BMI indicated that these relationships held independently of potential demographic confounders (P < .001 for all). The number of patients meeting the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) for the HOS-ADL, HOS-SS, and mHHS was significantly higher in athletes aged ≤25 years versus those aged >25 years and for athletes versus nonathletes (P < .05 for all). Further, 189 of 194 athletes returned to sports at a mean of 6.0 ± 3.9 months postoperatively, with 93.7% reporting returning to the same or higher level of competition.

Conclusion

Among female patients undergoing hip arthroscopic surgery for FAIS, patients considered athletes achieved superior clinical outcomes compared with patients considered nonathletes. In addition, younger female athletes had higher rates of achieving the MCID and PASS for all PRO measures.