Cost-Effectiveness of Hip Arthroscopy for Treatment of Femoroacetabular Impingement Syndrome and Labral Tears: A Systematic Review

Osteochondroplasty with or without labral repair is more cost-effective than arthroscopic lavage with or without labral repair for treatment of young adults with femoroacetabular impingement: A cost-utility analysis based on data from a randomized controlled trial

OBJECTIVES

The objective of this study was to conduct a cost-utility analysis of osteochondroplasty with or without labral repair compared to arthroscopic lavage with or without labral repair for femoroacetabular impingement (FAI) from a Canadian public payer perspective.

METHODS

A Markov model was constructed to compare the lifetime quality-adjusted life years (QALYs) and costs of the two treatment strategies. The target population was surgical FAI patients aged 36 years. The primary data source was patient-level data from the Femoroacetabular Impingement Randomised Controlled Trial, which evaluated the efficacy of the surgical correction of FAI via arthroscopic osteochondroplasty with or without labral repair compared to arthroscopic lavage with or without labral repair in Canada. Long-term data were extrapolated using a generalized gamma model. The primary outcome was the incremental cost-effectiveness ratio, calculated by dividing the difference in costs by the difference in QALYs between osteochondroplasty and lavage, with or without labral repair. Probabilistic sensitivity analyses and one-way sensitivity analyses were used to characterize uncertainty of model parameters and assumptions.

RESULTS

Over a lifetime horizon, osteochondroplasty, with or without labral repair, had a greater expected benefit (0.63 QALYs gained per patient) and lower costs ($955.89 saved per patient), as compared with lavage with or without labral repair. Probabilistic sensitivity analyses demonstrated that the probability of osteochondroplasty, with or without labral repair, being cost-effective was 90.5% at a commonly used willingness-to-pay threshold of $50,000/QALY in Canada. Across all one-way sensitivity analyses, osteochondroplasty with or without labral repair remained a cost-effective option.

CONCLUSION

Over a lifetime time horizon, osteochondroplasty, with or without labral repair, is a cost-effective treatment strategy for young adults with FAI. Future research involving real-word data is needed to further validate these findings.

LEVEL OF EVIDENCE

III.

Trends of hip arthroscopy in Italy show an increase over the years: A nationwide study from 2001 to 2016

Purpose

Hip arthroscopy has gained popularity among orthopaedic procedures over the last decade. The present study aims to evaluate the trends of hip arthroscopy procedures in Italy analysing data recorded by the Italian Ministry of Health, reporting demographics, length of hospitalisation (LOS), diagnosis and the economic impact of the procedure.

Methods

The National Hospital Discharge records reported by the Italian Ministry of Health were used, analysing the data regarding hip arthroscopy procedures performed in Italy between 2001 and 2016. A total of 4022 hip arthroscopies were performed in Italy in the adult population.

Results

The present study shows more males being exposed to the procedure, while the mean age of females was always higher than that of males during the 16-year study period. The mean LOS was 2.6 ± 3.2 days, and every procedure had a mean Italian hospital reimbursement from 1361€ to 1512€. Hip arthroscopy procedures have increased substantially between the years 2001 and 2016, as well as the costs related to the surgery.

Conclusions

The findings of this study constitute valuable clinical and scientific evidence for the healthcare system, which is useful not only for the formulation and improvement of national healthcare policies but also to improve awareness and accessibility of hip arthroscopy.

Level of Evidence

Level II.

Hip Arthroscopy Trends: Increasing Patient Out-of-Pocket Costs, Lower Surgeon Reimbursement, and Cost Reduction With Utilization of Ambulatory Surgery Centers

PURPOSE

To (1) report on trends in immediate procedure reimbursement, patient out-of-pocket expenditures, and surgeon reimbursement in hip arthroscopy (2) compare trends in ambulatory surgery centers (ASC) versus outpatient hospitals (OH) utilization; (3) quantify the cost differences (if any) associated with ASC versus OH settings; and 4) determine the factors that predict ASC utilization for hip arthroscopy.

METHODS

The cohort for this descriptive epidemiology study was any patient over 18 years identified in the IBM MarketScan Commercial Claims Encounter database who underwent an outpatient hip arthroscopy, identified by Current Procedural Terminology codes, in the United States from 2013 to 2017. Immediate procedure reimbursement, patient out-of-pocket expenditure, and surgeon reimbursement were calculated, and a multivariable model was used to determine the influence of specific factors on these outcome variables. Statistically significant P values were less than .05, and significant standardized differences were more than 0.1.

RESULTS

The cohort included 20,335 patients. An increasing trend in ASC utilization was observed (P = .001), and ASC utilization for hip arthroscopy was 32.4% in 2017. Patient out-of-pocket expenditures for femoroacetabular impingement surgery increased 24.3% over the study period (P = .003), which was higher than the rate for immediate procedure reimbursement (4.2%; P = .007). ASCs were associated with $3,310 (28.8%; P = .001) reduction in immediate procedure reimbursement and $47 (6.2%; P = .001) reduction in patient out-of-pocket expenditure per hip arthroscopy.

CONCLUSIONS

ASCs provide a significant cost difference for hip arthroscopy. Although there is an increasing trend toward ASC utilization, it remains relatively low at 32.4% in 2017. Thus, there are opportunities for expanded ASC utilization, which is associated with significant immediate procedure reimbursement difference of $3,310 and patient out-of-pocket expenditure difference of $47 per hip arthroscopy case, ultimately benefiting healthcare systems, surgeons, and patients alike.

LEVEL OF EVIDENCE

Level III, retrospective comparative trial.

Modified Technique for Labral Reconstruction of Hip Joint Using Autologous Iliotibial Band (ITB)-Make Labral Reconstruction Stress-Free

Current treatments for labral tear include surgical debridement, arthroscopic repair, and labral reconstruction. Although labral debridement and labral suture repair are suitable for most patients, labral reconstruction is the first treatment option when there is extensive labral degeneration or defect. Often, however, the labral degeneration or defect is only detected intraoperatively; therefore, the surgeon should always have a backup plan. The current labral reconstruction technique has shortcomings such as long operation time, difficult autograft harvesting, cumbersome graft preparation, and the need for a large surgical incision and re-sterilization and draping. To address these problems, we developed a modified technique for draping and surgery. This technique ensures preparedness for labral reconstruction during each hip arthroscopic surgery. The method also simplifies the steps for autologous iliotibial band graft harvesting and shortens operative time. We have achieved satisfactory clinical results with use of this technique over the past 2 years. In this Technical Note, we describe our technique. This modified labral reconstruction technique greatly improves surgical efficiency and could be a promising surgical technique for hip labral reconstruction.

Editorial Commentary: Hip Arthroscopy for Patients With Decreased Center-Edge Angle and Bipolar Cartilage Lesions Is Associated With Early Conversion to Total Hip Arthroplasty

The utilization of hip arthroscopy to treat femoroacetabular impingement has continued to grow year after year. Clinical studies and cost-effectiveness analyses have repeatedly shown the benefits of hip arthroscopy in improving quality of life, offering much promise to this patient population. Through years of research, a more comprehensive understanding of impingement pathologies has brought improving surgical techniques. However, predictors of poor outcomes are still not entirely understood. Although many patients attain significant relief, some patients do not attain meaningful improvement. Meaningful improvement can be found even years after hip arthroscopy, but this is a long road for patients who do not find sustained relief. Thus, as with defining appropriate indications for hip arthroscopy, it is equally important to identify factors that may instead suggest alternative treatment regimens for patients with hip pathology who may not benefit from arthroscopic intervention. However, rather than exclude large groups entirely based on the presence of certain factors such as increased age or arthritis, the goal should be to understand the nuances among patients in these higher-risk groups to identify those who may still find success with hip arthroscopy.

Hip Arthroscopy for Femoroacetabular Impingement-Associated Labral Tears: Current Status and Future Prospects

Femoroacetabular impingement (FAI) has emerged as a common cause of hip pain, especially in young patients. While the exact cause of FAI is unknown, it is thought to result from repetitive microtrauma to the proximal femoral epiphysis leading to abnormal biomechanics. Patients typically present with groin pain that is exacerbated by hip flexion and internal rotation. Diagnosis of FAI is made through careful consideration of patient presentation as well as physical exam and diagnostic imaging. Use of radiographs can help diagnose both cam and pincer lesions, while the use of MRI can diagnose labral tears and cartilage damage associated with FAI. Both non-operative and surgical options have their role in the treatment of FAI and its associated labral tears; however, hip arthroscopy has had successful outcomes when compared with physical therapy alone. Unfortunately, chondral lesions associated with FAI have had poorer outcomes with a higher conversion rate to arthroplasty. Capsular closure following hip arthroscopy has shown superior clinical outcomes and therefore should be performed if possible. More recently, primary labral reconstruction has emerged in the literature as a good option for irreparable labral tears. While non-operative management may have its role in treating patients with FAI, hip arthroscopy has developed a successful track record in being able to treat cam and pincer lesions, chondral damage, and labral injuries.

Less hip range of motion is associated with a greater alpha angle in people with longstanding hip and groin pain

PURPOSE

A higher alpha angle has been proposed to correlate with lower hip range of motion, but the association in people with longstanding hip and groin pain is currently unclear. The aims were to: (1) assess the association between range of motion and alpha angle in patients with longstanding hip and groin pain; (2) examine if a cut-off value in range of motion variables could identify patients with an alpha angle above or below 60°.

METHODS

Seventy-two participants were consecutively recruited from an orthopaedic department after referral for hip- and groin-related pain. Passive hip range of motion was measured in flexion, internal rotation with 90° hip flexion, internal rotation in neutral hip position, external rotation with 90° hip flexion, and abduction. The alpha angle was calculated from a frog-leg lateral radiograph. Linear regression examined the association between range of motion and alpha angle, and an ROC-curve analysis was performed to identify the sensitivity and specificity of range of motion cut-offs.

RESULTS

Lower range of motion in internal rotation in flexion, external rotation, and abduction were associated with higher alpha angle. Internal rotation of 27° or less displayed good sensitivity (81%) and specificity (85%) to detect an alpha angle above 60°, while a cut-off of 41° in external rotation and 27° in abduction showed a sensitivity of 72% and specificity of 50% and 60%, respectively.

CONCLUSION

Less internal rotation in flexion, external rotation, and abduction are associated with a greater alpha angle in a cohort of people with longstanding hip and groin pain. A cut-off of 27° in internal rotation has good sensitivity and specificity to identify people with an alpha angle above or below 60° and have the potential to be used in the clinical setting to identify patients that require further imaging, or that are unlikely to have cam morphology.

LEVEL OF EVIDENCE

II.