Does obesity affect outcomes after hip arthroscopy? A cohort analysis

Socioeconomic Factors Including Patient Income, Education Level, and Health Insurance Influence Postoperative Secondary Surgery and Hospitalization Rates Following Hip Arthroscopy

PURPOSE

To evaluate a large cross-sectional sample of patients utilizing administrative database records and analyze the effects of income, insurance type, and education level on outcomes after hip arthroscopy, including 2-year revision surgery, conversion to total hip arthroplasty (THA), and 90-day hospitalizations.

METHODS

Current Procedural Terminology codes were used to query the PearlDiver Mariner database from October 2015 to January 2020 for patients undergoing hip arthroscopy with a minimum 2-year follow-up. Patients were categorized by mean family income in their zip code of residence (MFIR), health insurance type, and educational attainment in their zip code of residence (EAR). Two-year revision arthroscopy, conversion to THA, and 90-day hospital readmissions or emergency department (ED) visits were analyzed along socioeconomic strata.

RESULTS

Multivariate analysis of 33,326 patients revealed that patients with MFIR between $30,000 and $70,000 had lower odds of 2-year revision arthroscopy (odds ratio [OR], 0.63; P < .001), THA conversion (OR, 0.76; P = .050), and 90-day readmission (OR, 0.53; P = .007) compared to MFIR >$100,000. Compared to patients with commercial insurance, patients with Medicare had lower odds of revision arthroscopy (OR, 0.60; P = .035) and THA conversion (OR, 0.46, P < .001) but greater odds of 90-day readmission (OR, 1.74; P = .007). Patients with Medicaid had higher odds of 90-day ED visits (OR, 1.84; P < .001). Patients with low EAR had higher odds of revision arthroscopy (OR, 1.42; P = .005) and THA conversion (OR, 1.58; P = .002) compared to those with high EAR.

CONCLUSIONS

Following hip arthroscopy, patients residing in areas with lower mean family income were less likely to undergo reoperations and readmissions. Medicare patients showed lower reoperation but higher readmission odds, while Medicaid patients showed higher odds of ED visits. Additionally, higher educational attainment in the zip code of residence is protective against future reoperation.

LEVEL OF EVIDENCE

Level III, retrospective case series.

Editorial Commentary: Obesity Is Associated With Lower Hip Function Pre- and Postoperatively and Increased Time to Patient Acceptable Symptom State After Hip Arthroscopy

In 2015, worldwide, there were more than 1.9 billion adults classified as having overweight (body mass index [BMI] >25), with 600 million of these individuals meeting the definition of obesity (BMI >30). Hip arthroscopy in patients with obesity can lead to improve outcomes, albeit with lower absolute levels of patient-reported outcome scores and with increased risk of complications and conversion rates to total hip arthroplasty when compared with their counterparts without obesity. Importantly, a significantly longer time to patient acceptable symptoms state achievement is seen for patients with class I obese than patients with normal BMI. Unfortunately, the hip is quite susceptible to the effects of obesity, with greater acetabular depth/deformity, reduced femoral head cartilage, greater forces experienced with ambulation, and a predisposition to femoroacetabular impingement syndrome. Thus, almost 42% of patients operated on in North America for femoroacetabular impingement syndrome are classified as having overweight or obesity. This does not need to deter from the consideration of arthroscopic hip surgery in the population with obesity; rather, it supports a discussion between surgeon and patient on expectations and timeline for improvement.

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

BACKGROUND

Femoroacetabular impingement (FAI) is a major cause of hip pain in young adults and athletes. Surgical treatment of FAI is recommended in cases of failed nonoperative treatment that have the typical clinical and radiographic findings. At present, the role of risk factors for revision surgery and progression to total hip arthroplasty (THA) in patients with FAI is still unclear.

PURPOSE

To investigate the possible association between (1) rate of revision and progression to THA and (2) patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

The present systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In October 2020, the main online databases were accessed. All articles concerning surgical correction for selected patients with FAI were accessed. Patient characteristics, type of intervention, radiographic parameters, physical examination, and pre- and postoperative scores were assessed. The outcomes of interest were the possible association between these variables and the rate of revision and subsequent progression to THA using a multivariate analysis through the Pearson product-moment correlation coefficient.

RESULTS

Data from 99 studies (9357 procedures) were collected. The median follow-up was 30.9 months (interquartile range, 24.0-45.0). The mean ± SD age was 33.4 ± 9.3 years; mean body mass index (BMI), 24.8 ± 4.8; percentage right side, 55.8% ± 8.0%; and percentage female sex, 47.5% ± 20.4%. The overall rate of revision was 5.29% (351 of 6641 patients), while the rate of subsequent progression to THA was 3.78% (263 of 6966 patients). Labral debridement (P < .0001), preoperative acetabular index (P = .01), and BMI (P = .03) all showed evidence of a statistically positive association with increased rates of THA. No other statistically significant associations were found between patient characteristics, type of lesion, family history of hip disease, type of intervention, radiographic parameters, physical examination, or pre- and postoperative scores and the rate of revision and/or progression to THA.

CONCLUSION

Although surgical procedures to treat FAI led to satisfactory outcomes, there was a revision rate of 5.29% in the 9357 procedures in the present systematic review. The rate of progression to THA after a median follow-up of 30 months was 3.78%. Patients who have a higher BMI and/or have a pathologic acetabular index and/or undergo labral debridement during correction of FAI are more at risk for a subsequent THA. We advocate additional education of this patient population in terms of expected outcomes and suggest surgical labral repair instead of debridement if needed.

High Body Mass Index Does Not Adversely Affect Outcomes in High-Level Athletes Undergoing Primary Hip Arthroscopy: A Propensity-Matched Comparison With Minimum 2-Year Follow-up

BACKGROUND

The effect of high body mass index (BMI) on outcomes in athletes has not been established.

PURPOSE

(1) To report minimum 2-year patient-reported outcome (PRO) scores and return to sports (RTS) for high-level athletes with high BMI undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and (2) to compare results with a propensity-matched control group of high-level athletes with a normal BMI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were collected on all professional, collegiate, and high school athletes who had a high BMI (>30) and who had undergone primary hip arthroscopy for FAIS between January 2010 and December 2018. RTS status and minimum 2-year PROs were collected for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), and visual analog scale (VAS) for pain. The percentage of patients achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were also recorded. These patients were propensity matched in a 1:3 ratio to high-level athletes with a normal BMI for comparison.

RESULTS

A total of 30 high-level athletes with a high BMI were included with a mean follow-up of 49.4 ± 29.5 months. They demonstrated significant improvement from preoperatively to latest follow-up for mHHS, NAHS, HOS-SSS, and VAS (P < .001). When outcomes were compared with a propensity-matched control group of 90 athletes with a normal BMI, athletes with a high BMI had worse acetabular cartilage injury and were more likely to undergo acetabular microfracture (P < .001). Athletes with a high BMI demonstrated lower postoperative scores for NAHS when compared with athletes with a normal BMI (88.06 ± 9.37 [range, 60-100] and 90.25 ± 10.79 [range, 48.75-100], respectively; P = .049). Athletes with a high BMI also demonstrated worse postoperative scores for HOS-SSS when compared with athletes with a normal BMI (77.22 ± 18.31 [range, 22.22-100] and 82.38 ± 22.79 [range, 2.78-100], respectively; P = .038). Rates of achieving MCID for the high-BMI and normal-BMI groups were comparable in mHHS (90.0% and 77.8%, respectively; P = .185) and HOS-SSS (90.0% and 82.2%, respectively; P = .397). PASS rates were also comparable between the high- and normal-BMI groups for mHHS (90.0% and 87.8%, respectively; P > .999) and HOS-SSS (70.0% and 71.1%, respectively; P = .908). Athletes with a high BMI also returned to sports at a lower rate compared with athletes with a normal BMI, but this did not reach statistical significance (P = .479).

CONCLUSION

Athletes with a high BMI undergoing primary hip arthroscopy for FAIS demonstrated significant improvement in PROs and favorable rates achieving clinically meaningful improvement. When compared with a control group of high-level athletes with a normal BMI, they exhibited similar rates of achieving psychometric thresholds and RTS rates. At short-term follow-up, high BMI did not adversely affect outcomes of high-level athletes undergoing primary hip arthroscopy.

Surgical Treatment of Femoroacetabular Impingement: Minimum 10-Year Outcome and Risk Factors for Failure

Femoroacetabular impingement (FAI) is a well-known cause of hip pain and dysfunction in young adults. Surgical treatment has been widely popularized during the past decade. However, most reported results have been limited to short-term and intermediate-term follow-up. The long-term success rate and risk factors for failure are largely unknown. This study aimed to report the long-term (minimum, 10 years) clinical outcomes of surgical treatment of FAI and to describe the clinical and radiographic parameters associated with the failure of treatment involving femoroacetabular osteoplasty (FAO) and labral repair.

Six-Month Outcome Scores Predicts Short-Term Outcomes After Hip Arthroscopy

PURPOSE

To determine whether early patient-reported outcome improvements in the 6 months after surgery are predictive of achieving a patient acceptable symptomatic state (PASS) at 2 years.

METHODS

A prospectively collected database was retrospectively reviewed. Inclusion criteria included patients ≥18 years of age, Tönnis grade 0 or 1 changes, radiographic imaging consistent with femoroacetabular impingement or labral pathology, a primary diagnosis of symptomatic femoroacetabular impingement for which they underwent primary hip arthroscopy, and baseline, 6-month, and 2-year modified Harris Hip Score (mHHS) scores. Revision cases were excluded. Receiver operating characteristic curve analysis was conducted to determine whether 6-month change in mHHS was a predictor for achieving PASS at 2 years.

RESULTS

There were 173 patients (mean age: 39.8, 61.8% female) included within the study. Patients who do not achieve the minimal clinically important difference (MCID), defined as a change of 8 points in mHHS, by 6 months (n = 21) tended to have significantly lower mHHS scores at 1 year and 2 years compared with those who did (n = 152). Only 52% of patients who did not achieve MCID by 6 months achieved MCID by 2 years (vs 98% for those that did) and only 24% achieved PASS by 2 years (vs 88% that did). Using the MCID as a cutoff for improvement in mHHS at 6 months results in a 96% sensitivity but 47% specificity for predicting PASS achievement at 2 years. Using 24 points of improvement in mHHS as a cutoff at 6 months improves sensitivity and specificity to 81% and 80%, respectively.

CONCLUSIONS

Early improvement in mHHS scores is associated with 2-year outcomes. Patients who do not achieve MCID within 6 months of surgery have a high rate of not achieving PASS at 2 years.

LEVEL OF EVIDENCE

IV, case series study.

Parameters affecting baseline hip function in patients with cam-derived femoroacetabular impingement syndrome: data analysis from the German Cartilage Registry

BACKGROUND

Using the database of the German Cartilage Registry (KnorpelRegister DGOU), this study aims to present patient- and joint-related baseline data in a large cohort of patients with cam-derived femoroacetabular impingement syndrome (FAI) and to detect symptom-determining factors.

MATERIALS AND METHODS

Requiring cam morphology as the primary pathology, 362 patients were found to be eligible for inclusion in the study. The assessment of preoperative baseline data was performed using the patient-reported outcome measure-International Hip Outcome Tool (iHOT-33). Descriptive statistics were performed to present baseline data. Univariate and multiple regression with post hoc testing were used to identify patient- and joint-related factors that might affect the preoperative iHOT-33 and its subscores, respectively.

RESULTS

The study collective's mean age was 36.71 ± 10.89 years, with 246 (68%) of them being male. The preoperative mean iHOT-33 total was 46.31 ± 20.33 with the subsection "sports and recreational activities" presenting the strongest decline (26.49 ± 20.68). The parameters "age," "sex," "body mass index" (BMI), and the confirmation of "previous surgery on the affected hip" were identified to statistically affect the preoperative iHOT-33. In fact, a significantly lower mean baseline score was found in patients aged > 40 years (p < 0.001), female sex (p < 0.001), BMI ≥ 25 kg/m² (p = 0.002) and in patients with previous surgery on the affected hip (p = 0.022). In contrast, the parameters defect grade and size, labral tears, and symptom duration delivered no significant results.

CONCLUSIONS

A distinct reduction in the baseline iHOT-33, with mean total scores being more than halved, was revealed. The parameters "age > 40 years," "female sex," "BMI ≥ 25," and confirmation of "previous surgery on the affected hip" were detected as significantly associated with decreased preoperative iHOT-33 scores. These results help to identify symptom-defining baseline characteristics of cam-derived FAI syndrome.

TRIAL REGISTRATION

The German Cartilage Registry is conducted in accordance with the Declaration of Helsinki and registered at germanctr.de (DRKS00005617). Registered 3 January 2014-retrospectively registered. The registration of data was approved by the local ethics committees of every participating institution. Primary approval was given by the ethics committee at the University of Freiburg (No. 105/13). https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00005617.

Is Arthroscopic Hip Labral Repair/Reconstruction Surgery Effective for Treating Femoroacetabular Impingement in the Presence of Osteoarthritis?

OBJECTIVE

To investigate clinical outcomes after arthroscopic labral preservation surgery for femoroacetabular impingement (FAI) in the presence of osteoarthritis (OA) compared with FAI without significant OA.

DESIGN

Retrospective case-control study.

SETTING

Department of Orthopaedic Surgery and Sports Medicine, Hospital of Academic Institute.

PATIENTS

Femoroacetabular impingement patients (n = 97; ≥35 years) undergoing arthroscopic FAI correction with labral preservation surgery from March 2009 to April 2014 were enrolled in this study.

INTERVENTIONS

Patients were divided into 2 groups: FAI group (79 patients), with Tonnis grade 0 or 1, and FAI + OA group (18 patients), with Tonnis grade 2 or 3.

MAIN OUTCOME MEASURES

We examined the clinical outcomes using the Modified Harris Hip Score (MHHS), Nonarthritic Hip Score (NAHS), and the conversion rate to total hip arthroplasty (THA).

RESULTS

No significant differences existed between the 2 groups with respect to age, sex, follow-up period, or preoperative MHHS or NAHS. The mean MHHS and NAHS at the final follow-up were significantly lower in the FAI + OA group than in the FAI group. There was a significant difference in the rate of conversion to THA and failure between the 2 groups (THA 5% vs 50%) (failure 15% vs 67%).

CONCLUSION

Patients with FAI in the presence of OA did not improve after arthroscopic labral preservation surgery and had a high conversion rate to THA.

LEVEL OF EVIDENCE

Level III.

Hip arthroscopy and T-shaped capsular plication for the treatment of borderline dysplasia: a minimum 2-year follow-up

PURPOSE

The aim of the study was to evaluate the clinical outcomes of patients treated arthroscopically for symptomatic borderline dysplasia of the hip (BHD) with a T-shaped capsular plication, with a minimum follow-up of 24 months.

METHODS

Twenty-seven patients who had undergone hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All patients were clinically evaluated prior to surgery (T₀) and at two consecutive follow-ups (T₁: 12 ± 1.2 months; T₂: 52.0 ± 23.2 months) using the visual analogue scale (VAS) pain score, the Hip Outcome Score in activities of daily living (HOS-ADL) and sport-specific subscale (HOS-SSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and Short Form-12 in its physical (PCS) and mental component scores (MCS). We also evaluated the presence of correlations and analysed the possible differences between subgroups.

RESULTS

We found a significant difference for HOS-ADL, HOS-SSS, VAS and WOMAC with the Friedman test for repeated measures through time points (p < 0.0001), but not for MCS. All clinical scores reported a significant improvement compared to the previous time point (p < 0.05), with the exception of HOS-SSS, for which p = 0.2570 between T₁ and T₂. The body mass index was positively correlated with preoperative VAS (R = 0.42857; p = 0.0257) and negatively correlated with PCS at T₀ (R = - 0.40999; p = 0.0337) and with PCS (R = - 0.40491; p = 0.0362), MCS (R = - 0.45939; p = 0.0159) and WOMAC (R = - 0.40573; p = 0.0216) at T₂. No complications were reported in our cohort.

CONCLUSIONS

The results of the current study confirm that patients with intra-articular hip pathology and concomitant BHD (LCEA 20°-25°) can benefit from arthroscopic treatment and that T-shaped capsular plication is one of the available options. Orthopaedic surgeons specialising in hip arthroscopy should consider arthroscopy for the treatment of symptomatic BHD for stabilising and strengthening the joint. Future studies should focus on finding out which type of patients can benefit most from this procedure.

LEVEL OF EVIDENCE IV

Prospective Case Series.

Successful return to sport in patients with symptomatic borderline dysplasia following hip arthroscopy and T-shaped capsular plication

PURPOSE

This study aims to evaluate the return to sport and correlations of patients with symptomatic borderline hip dysplasia (BHD) after hip arthroscopy and T-shaped capsular plication at a minimum follow-up of 24 months.

METHODS

Twenty-five patients who underwent hip arthroscopy and T-shaped capsular plication for symptomatic BHD were included in the study. All the patients were evaluated clinically prior to surgery (T₀) and at two consecutive follow-ups (T₁:15 ± 1.2 months and T₂: 53.9 ± 23.2 months) using the visual analogue scale (VAS) pain score, whereas sports activity was assessed by the Hip Outcome Score Sport Specific Subscale (HOS-SSS), the University of California, Los Angeles (UCLA) activity scale, the Tegner score and the physical component (PCS) of the Short Form-12 (SF-12). Furthermore, the presence of correlations and the possible differences between subgroups were evaluated and analysed.

RESULTS

A significant difference was found for HOS-SSS, VAS, Tegner, UCLA and PCS with the Friedman test for repeated measures through time points (p < 0.0001). Moreover, all the scores reported significant improvement compared to the previous time point (p < 0.0001) except the HOS-SSS between T₁ and T₂ (n.s.). Body Mass Index (BMI) was negatively correlated with HOS-SSS at T₀ (rho = - 0.526 p = 0.006) and T₁ (rho = - 0.425; p = 0.034), with Tegner at each follow-up (T₀: rho = - 0470 p = 0.017; T₁: rho = - 0.450; p = 0.024; T₂: rho = - 0.448; p = 0.024), with UCLA at T₁ (rho = - 0.396 p = 0.049), with pre-operative PCS (rho = - 0.413 p = 0.0401), and positively correlated with pre-operative VAS (rho = 0.436 p = 0.0291).

CONCLUSIONS

Hip arthroscopy and T-shaped capsular plication in young patients with symptomatic BHD demonstrates a significant increase in return to sport and physical activity and low risk of complications. T-shaped capsular plication procedure may be considered in young and active patients for whom non-operative treatment failed and who have a significant limitation in sports activity; in these patterns of patients, the ideal treatment should reliably allow fast recovery in combination with very low invasiveness which will prevent osteoarthritis. The results of this study provide more accurate information regarding return to sport in patients with BHD after hip arthroscopy and T-shaped capsular plication.

LEVEL OF EVIDENCE

Level IV.

Obesity is associated with less favorable outcomes following hip arthroscopic surgery: a systematic review and meta-analysis

PURPOSE

The aim of this study was to systematically review the existing literature comparing the postoperative outcomes after following hip arthroscopy in obese and non-obese patients.

METHODS

Studies comparing the outcomes following hip arthroscopy of obese and non-obese patients were systematically identified via a computer-assisted literature search of Pubmed (Medline), EMBASE, and Cochrane Library using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. Studies comparing the outcome of hip arthroscopy in different body mass index (BMI) groups were included. Data including patient-reported outcome measures (PROMs), revision arthroscopy rate, conversion rate to total hip arthroplasty (THA), and complications were collected. The methodological index for non-randomized studies (MINORS) and Newcastle-Ottawa Scale (NOS) were used to assess the quality of each study quality. The effect of heterogeneity was quantified by calculating the I² value.

RESULTS

A total of eight studies were finally included in the qualitative analysis, and three studies of high quality involving 373 hips were included in the quantitative assessment. All the studies defined obesity as a BMI of  ≥ 30 kg/m². The modified Harris Hip Score and the Non-Arthritic Hip Score were 5.1 (95% CI 1.1-9.1) and 9.0 (95% CI 5.0-13.1) points lower, respectively, in the obese group than in the non-obese group. The pooled odds ratios were 1.2 (95% CI 0.5-2.7) for revision arthroscopy, 2.4 (95% CI 1.3-4.6) for conversion to THA, and 3.2 (95% CI 1.2-8.6 for complications in favor of the non-obese group. The heterogeneity was low in all outcome assessments (I² 0-18%).

CONCLUSION

Obese patients had significantly lower PROMs than non-obese patients following hip arthroscopic surgery, and the THA conversion and complication rates were 2.4 times and 3.2 times higher, respectively. Understanding the effect of obesity on hip arthroscopy will allow appropriate surgical indications for surgery to be further refined and help obese patients to understand their individual risk profile.

LEVEL OF EVIDENCE

Systematic review of Level III-IV studies, Level IV.

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.

Hip arthroscopy in France: An epidemiological study of postoperative care and outcomes involving 3699 patients

BACKGROUND

Hip arthroscopy is a surgical procedure that is becoming more and more prevalent in France. Even though indications are now well-established little is still known about patient outcomes. Therefore, the purpose of our retrospective study was to: (1) describe the circumstances in which hip arthroscopies are being performed; (2) study arthroscopy and arthroplasty reoperation rates; (3) assess the incidence of readmissions for complications.

HYPOTHESIS

Hip arthroscopy in France produced similar results to those observed in other countries.

MATERIALS AND METHODS

We conducted a cohort study from January 2008 to December 2014 in the French population using the national hospital discharge database called "Programme de médicalisation des systèmes d'information (PMSI)." We included all admissions that had a hip arthroscopy code and analyzed readmissions for conversion to hip arthroplasty, revision hip arthroscopy and complications (without being able to provide detailed descriptions). Risk factors associated with conversion, revision and readmission for complications were studied after performing a population analysis.

RESULTS

A total of 3,699 patients were included over a period of seven years. The mean age was 40 years, with women being significantly older (mean age of 43 years) than men (38 years) (p<0.05). The number of procedures increased from 240 in 2008 to 702 in 2014. Synovectomies (67.9%; 2514/3699) and surgical bone procedures (acetabuloplasty or femoroplasty) (47.3%; 1751/3699) were the main procedures performed during the primary arthroscopy. In total, 410 patients underwent a conversion to arthroplasty, 231 patients had a revision arthroscopy, and 126 patients suffered a complication. Five years after the index procedure, the conversion rate was 16.3%, revision rate was 8.2%, and readmission rate for a postoperative complication was 5%. The main risk factor associated with conversions was [Hazard ratio (HR) and 95% Confidence Index (CI)] an age between 40 and 79 years during the first arthroscopy [3.04 (2.40; 3.87) compared with the reference class of 25-39 years]. Patients between ages 16 to 24 years during the first arthroscopy (0.35 [0.20; 0.61] compared with the reference class of 25-39 years) had a decreased risk of conversion (HR and 95% CI). The main risk factors associated with revisions were: synovectomies [1.90 (1.34; 2.70)] and surgical bone procedures on the femoral neck and/or the acetabulum [1.82 (1.36; 2.4)]. The risk factor associated with complication-related readmissions was an age greater than 40 years [2.23 (1.43; 3.49)].

CONCLUSION

Unlike the international literature, our study population was largely male. The rates of revision (8.2% after five years) and conversion to arthroplasty (16.3% after five years) were relatively low and comparable to the different international studies. This procedure, which is not widely performed, is growing in popularity, has low morbidity and remains an interesting approach given the revision and conversion rates after five years. The implementation of specific coding for arthroscopic hip procedures and the pathologies to be treated seems warranted.

LEVEL OF EVIDENCE

IV; descriptive epidemiological study.

The Influence of Body Mass Index on Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome: Five-Year Results in 140 Patients

BACKGROUND

Significant short-term improvements in function and pain after arthroscopic management of femoroacetabular impingement syndrome (FAIS) have been demonstrated regardless of mass index (BMI). No studies have reported the influence of obesity on mid- to long-term outcomes.

PURPOSE

To evaluate the effect of BMI class on 5-year patient outcomes after arthroscopic treatment of FAIS.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A retrospective review of a prospective database was performed to identify patients who underwent arthroscopic treatment for FAIS. A matched-pair analysis for age and sex was performed in a 1:1:2:3 fashion for morbidly obese (BMI ≥35), obese (BMI = 30-34.9), overweight (BMI = 25-29.9), and normal weight (BMI = 18.5-24.9) patients, respectively. Patient characteristics, imaging, Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Subscale (HOS-SS) scores, modified Harris Hip Score (mHHS), and pain scores were recorded preoperatively, with the same outcome scores recorded at 5 years postoperatively, along with satisfaction scores. Standardized modern hip arthroscopy, with labral repair, acetabuloplasty, femoroplasty, and capsular plication followed by formalized rehabilitation, was performed for all patients. Absolute outcomes along with change in outcomes were assessed between BMI groups. A between-group analysis was also conducted evaluating achievement of the minimal clinically important difference (MCID), patient acceptable symptomatic state (PASS), and substantial clinical benefit (SCB) for any outcome score. A multivariable analysis was additionally included to evaluate outcomes adjusting for known confounding variables.

RESULTS

A total of 140 patients with mean follow-up of 62.1 ± 6.5 months were identified: 20 morbidly obese, 20 obese, 40 overweight, and 60 normal weight. There were significant improvements for HOS-ADL, HOS-SS, and mHHS scores in the normal (all P < .0001) and overweight groups (all P < .0001), mHHS in the obese group (P = .0275), and no significant improvement in functional scores in the morbidly obese group (P > .05). Compared with normal controls, multivariable analysis, adjusting for confounders, showed similar improvement in HOS-ADL for patients in the overweight and obese groups, HOS-SS for patients in the overweight group, and mHHS for patients in the overweight and obese groups (all P > .05). All groups showed significant improvement in pain scores (all P < .01) that were not significantly different between groups in multivariable analysis (all P > .05). Obese BMI was associated with a 54.9-point decrease in 5-year HOS-SS, and morbidly obese BMI was associated with a 27.3, 35.0, and 23.7-point decrease in 5-year HOS-ADL, HOS-SS, and mHHS, respectively (all P < .05). Regarding surgical benefit in comparison with normal weight patients, patients in the overweight and obese groups were as likely to achieve MCID (reciprocal odds ratio [ROR]: 1.5 and 1.2, respectively, both P > .05), but patients in the morbidly obese group were not. All groups were significantly less likely than the normal weight group to achieve PASS (ROR: overweight 5.2, obese 14.1, morbidly obese 13.0; all P < .05) and SCB (ROR: overweight 3.9, obese 7.8, morbidly obese 20.3; all P < .05).

CONCLUSION

There were significant improvements in at least 1 outcome score across all BMI groups with arthroscopic treatment of FAIS. While the normal weight patients demonstrated universal improvement in all patient-reported outcomes and significantly greater likelihood of achieving PASS and SCB, the higher BMI groups still demonstrated significant improvement in function and pain, except for the morbidly obese group. Patients with morbid obesity demonstrated long-term pain improvement, although they did not experience functional improvement.

Treatment of type IV Pipkin fracture in patients with a high BMI via hip arthroscopy-assisted surgery: a case report

Pipkin type IV femoral head (FH) fracture-dislocations are usually treated via open surgery. There are many surgical approaches for the treatment of this difficult fracture depending on the fracture pattern. Obesity presents another challenging problem in surgical treatment and sometimes leads to a poorer outcome. We discuss herein a patient of a high body mass index (BMI) with a Pipkin type IV FH fracture who underwent open reduction internal fixation (ORIF) of anacetabular fracture with reconstruction plates and hip arthroscopy-assisted fixation of the FH fracture with two Herbert screws via the posterior approach. The intra-articular osteochondral loose bodies were excised by hip arthroscopy simultaneously. The joint congruency and screw positions were checked during surgery by arthroscopy. After 6 months, clinical and computed tomography (CT) follow-ups showed excellent results. The patient of a high BMI recovered immediately and had a satisfactory short-term outcome after hip arthroscopy-assisted surgery. We concluded that hip arthroscopy-assisted surgery is a viable option for the treatment of Pipkin type IV FH fracture-dislocations.

Approach to the Patient With Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement

There has been an exponential increase in the diagnosis and treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable pain relief and functional improvements after hip arthroscopy in properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery. The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon, and the postoperative physical therapy. This review highlights common causes of failure, including those related to residual bony deformity as well as capsular deficiency, and provides a framework for diagnosis and treatment of these patients.

Mini-Open Femoroacetabular Osteoplasty: Risk Factors for Failure and Conversion to Hip Arthroplasty

BACKGROUND

Surgical treatment of femoroacetabular impingement (FAI) has been increasing over the past decade with reports of favorable results in alleviating patient symptoms. However, progression of osteoarthritis in these patients may necessitate total hip arthroplasty (THA) for the treatment of unresolved or recurrent hip pain and accompanying disability. Identifying the risk factors for disease progression and treatment failure can help orthopaedic surgeons to select the appropriate patients for joint-preservation procedures and allow more informative discussions.

METHODS

With use of the prospective database of hip-preservation surgery at our institution, 652 patients (324 men and 328 women) with FAI who had undergone femoroacetabular osteoplasty (FAO) between December 2004 and April 2016 were identified. Treatment failure was defined as the need for THA. At the latest follow-up, 68 (9.08%)of 749 hips had undergone THA because of the recurrence of symptoms and the development of osteoarthritis. The groups of patients who had or had not undergone conversion to THA were compared with respect to age, sex, body mass index (BMI), surgeon experience, duration of preoperative symptoms, preoperative and postoperative alpha angles, radiographic parameters of hip dysplasia, a perioperative chondral lesion, labral abnormalities and interventions, acetabular retroversion, and severity of osteoarthritis (Tönnis grade).

RESULTS

The mean age (and standard deviation) at the time of the index FAO was 41.9 ± 10.5 years for patients who had had a failure of FAO, compared with 33.4 ± 11.1 years for those who had not. Risk factors for treatment failure included a longer mean symptomatic period before the FAO procedure, older age, higher mean BMI, the presence of hip dysplasia, acetabular retroversion, higher preoperative alpha angle, a full-thickness acetabular chondral lesion, Tönnis grade-1 and 2 osteoarthritis, labral hypertrophy, and total labral resection during FAO. The rate of failure was related to the experience of the surgeon, with fewer failures occurring in the later years of surgery as compared with the earlier years.

CONCLUSIONS

The present study identified a number of variables that influence the outcome of FAO. Surgeons performing hip-preservation procedures should be aware of these risk factors for failure, and a more cautious approach is recommended for patients with these risk factors.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Outcome Trends After Hip Arthroscopy for Femoroacetabular Impingement: When Do Patients Improve?

PURPOSE

To determine when patients reach critical thresholds of clinical improvement after hip arthroscopy for femoroacetabular impingement (FAI) using previously defined cutoffs for the minimal clinically important difference (MCID) and patient acceptable symptomatic state (PASS) and to identify risk factors for prolonged recovery.

METHODS

Consecutive patients with a diagnosis of FAI who underwent unilateral hip arthroscopy between January 2010 and January 2015 with at least 2 years of clinical follow-up were studied. The modified Harris Hip Score was collected prospectively at 6 consecutive time points. The number of patients reaching the MCID and PASS at each time point was determined.

RESULTS

During the study period, 340 consecutive hip arthroscopies were performed in 316 patients with a mean final follow-up period of 50 months (range, 29-84 months). The mean modified Harris Hip Score and percentage of patients reaching the MCID and PASS increased at each time point. At 2 years, 271 patients (93%) surpassed the MCID and 212 patients (73%) achieved the PASS. Female sex, age of 40 years or older, and body mass index of 30 or greater were associated with lower rates of achieving the MCID and PASS at set time points. Patients undergoing labral repair had superior PASS rates at 3 months and beyond than patients undergoing labral debridement alone. Patients who did not achieve the PASS by 3 months were more likely to require reoperation.

CONCLUSIONS

Hip arthroscopy for FAI results in increased patient-reported outcome measures at interval follow-up. Most patients reach critical thresholds of minimal and satisfactory clinical improvement. Patients who are female, older, or obese or who undergo labral debridement alone are less likely to reach these milestones at major time intervals. Patients who do not reach the PASS by 3 months are more likely to require reoperation.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Does Femoral Retroversion Adversely Affect Outcomes After Hip Arthroscopy for Femoroacetabular Impingement Syndrome? A Midterm Analysis

PURPOSE

To report 5-year outcomes of arthroscopic treatment of femoroacetabular impingement syndrome in patients with femoral retroversion compared with a control group of patients with normal femoral anteversion.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy between August 2008 and April 2013. Patients were included in analysis if they underwent hip arthroscopy during this period and had femoral version ≤0° calculated using magnetic resonance imaging. Exclusion criteria included prior ipsilateral hip conditions/surgeries or Tönnis grade >1. These patients were pair matched with patients having femoral anteversion between 10° and 20° based on gender, body mass index ± 10, and age ± 10 years. Patient-reported outcomes (PROs) were collected at 3 months and 1 year postoperatively and annually thereafter. An a priori power analysis was performed.

RESULTS

A total of 59 patients were identified as the experimental group out of 69 eligible for inclusion (86%). All 59 patients were matched, with a mean age of 37.4 years and mean body mass index of 26.9. Twenty patients were female, and 39 were male. These patients demonstrated significant improvement from their preoperative state in all patient-reported outcomes and visual analog score scores (P < .001). Thirty-eight patients met the threshold for minimal clinically important difference, and 35 achieved patient acceptable symptomatic state for the modified Harris Hip Score questionnaire. Seven patients converted to total hip replacement. No differences were noted between retroverted and control patients in any of the outcome measures collected, in pain or satisfaction ratings, in the frequency of or duration to secondary surgeries or in complication rate (P > .05).

CONCLUSIONS

Patients with femoral retroversion demonstrated significantly higher outcomes at minimum 5-year follow-up after undergoing arthroscopic hip surgery. These outcomes were not different from those of patients with normal femoral version. While femoral retroversion should not be considered a contraindication to hip arthroscopy, it should be carefully considered as a factor in patient selection and surgical planning.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Influence of body mass index on health-related quality of life after surgical treatment of intra-articular distal radius fractures. A retrospective 7-year follow-up study

Morbid obesity is associated with reduced health-related quality of life (HRQOL), increased morbidity and mortality. Little is known about the correlation between obesity and complex distal radius fractures (DRF). The purpose of this study was to examine the effect of being overweight on postoperative HRQOL after surgically treated intra-articular DRF. Fifty-three patients were included in this retrospective study with 7 years' mean follow-up (mean 7.2±0.4, range 6.4-7.9 years) after volar plating of an intra-articular DRF (AO-type C). All patients were categorized by their body mass index (BMI) into two study groups: group 1 (normal weight) with a BMI<25 (n=24); group 2 (obese) with a BMI≥25 (n=29). HRQOL and functional outcomes were assessed through range of motion (ROM) and four different scores - the 36-item short form health survey (SF-36), the disability of arm and shoulder score (DASH), the Gartland and Werley score and the Castaing score - along with X-rays to measure volar tilt, radial inclination, radial length and articular congruity. All HRQOL assessments and clinical outcomes were correlated to BMI by comparing group 1 versus group 2. There was no difference in terms of postoperative ROM. The group of normal weight patients achieved slightly better but non-significant results for the Gartland and Werley score. No differences were seen in the DASH score or SF-36. There were also no differences regarding the Castaing score. Overall, normal and obese patients had no significant differences their HRQOL and functionality after volar plating of DRF.

Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players

The purpose of this study was to determine the (1) return-to-sport rate for National Football League (NFL) players following femoroacetabular impingement surgery, (2) postoperative career length and games per season, (3) pre- and postoperative performance, and (4) postoperative performance compared with control players matched by position, age, years of experience, and performance. National Football League athletes who underwent hip arthroscopy for femoroacetabular impingement and matched controls were identified. A Bonferroni correction was used to control for multiple comparisons, with statistical significance set at P≤.007. Fifty-five players (63 surgeries) were analyzed (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). Forty-seven (53 surgeries, 84.1%) NFL players returned to sport at a mean of 6.7±3.8 months following surgery. There was no difference (P>.007) in the mean career length of players in the control group (3.7±2.2 years) vs players who underwent hip arthroscopy (3.5±2.1 years). There was no difference (P>.007) in mean games played per season of players in the control group (12.5±3.1) vs those who underwent hip arthroscopy (12.1±4.0). Quarterbacks had significantly better postoperative performance scores when compared with post-index matched controls (P=.007). The return-to-sport rate is high for NFL athletes after hip arthroscopy for femoroacetabular impingement. There were similar games per season and career lengths postoperatively compared with preoperatively and matched controls. Quarterbacks had significantly better postoperative performance when compared with matched controls. All other positions had similar postoperative performance compared with preoperatively and matched controls. [Orthopedics. 2019; 42(5):e423-e429.].

Performance and Return to Sport After Hip Arthroscopy for Femoroacetabular Impingement in Professional Athletes Differs Between Sports

PURPOSE

To determine (1) return-to-sport rates for National Football League, Major League Baseball, National Basketball Association, and National Hockey League (NHL) athletes after hip arthroscopy for femoroacetabular impingement syndrome, (2) postoperative return-to-sport rate differences between sports, (3) differences in postoperative career length and games per season, (4) differences in preoperative and postoperative performance, and (5) postoperative performance compared with that of matched control players.

METHODS

Professional athletes who underwent hip arthroscopy for femoroacetabular impingement syndrome were identified. Matched control players were identified by position, age, experience, and performance. Return to sport was defined as playing in at least 1 game after surgery. Continuous variables for each group were compared by using a 2-tailed paired-samples Student t test or χ² test. A Bonferroni correction was used to control for multiple comparisons with statistical significance defined by a P value < .002.

RESULTS

One hundred seventy-two players (86.4%) (mean age, 28.8 ± 5.2 years) were able to return to sport at an average of 7.1 ± 4.1 months. Athletes played 3.5 ± 2.4 years after surgery without significant differences between sports (P > .002). NHL players who underwent surgery played significantly fewer years (4.4 vs 3.3 years) (P < .001) and fewer games per season (4 fewer games) (P <.001) after surgery compared with control players. NHL players also had a significant decrease in performance after surgery compared with their performance before surgery (P < .001). In National Football League, Major League Baseball, and National Basketball Association athletes, no significant differences were found in games per season, career length, or preoperative performance compared with postoperative performance and performance of matched control players (P > .002).

CONCLUSION

The RTS rate for professional athletes after surgery for femoroacetabular impingement syndrome is high. Only NHL athletes had significantly shorter careers and played significantly fewer games per season compared with matched control players, with no difference between sports. NHL athletes had significantly worse postoperative performance compared with preoperative performance, with all other sports demonstrating a career-related decline similar to that of matched control players.

Effect of Cigarette Smoking on Patient-Reported Outcomes in Hip Arthroscopic Surgery: A Matched-Pair Controlled Study With a Minimum 2-Year Follow-up

Background

The rate of hip arthroscopic surgery has recently increased; however, there is limited literature examining patient-reported outcomes (PROs) in cigarette smokers.

Purpose/Hypothesis

The purpose of this study was to evaluate whether smoking status for patients undergoing hip arthroscopic surgery affects clinical findings and PRO scores. We hypothesized that patients who smoke and undergo primary hip arthroscopic surgery will have similar clinical examination findings and preoperative and postoperative PRO scores compared with nonsmoking patients.

Study Design

Cohort study; Level of evidence, 3.

Methods

Data were collected on all patients who underwent primary hip arthroscopic surgery from February 2008 to July 2015. A retrospective analysis of the data was then conducted to identify patients who reported cigarette use at the time of the index procedure. Patients were matched 1:2 (smoking:nonsmoking) based on sex, age within 5 years, labral treatment (repair vs reconstruction vs debridement), workers' compensation status, and body mass index within 5 kg/m². All patients were assessed preoperatively and postoperatively using 4 PRO measures: the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sport-Specific Subscale (HOS-SSS), and International Hip Outcome Tool-12 (iHOT-12). Pain was estimated using a visual analog scale. Satisfaction was measured on a scale from 0 to 10. Significance was set at P < .05.

Results

A total of 75 hips were included in the smoking group, and 150 hips were included in the control group. Preoperatively, the smoking group had significantly lower PRO scores compared with the control group for the mHHS, NAHS, and HOS-SSS. Both groups demonstrated significant improvement from preoperative levels. A minimum 2-year follow-up was achieved, with a mean of 42.5 months for the smoking group and 47.6 months for the control group (P = .07). At the latest follow-up, the smoking group reported inferior results for all outcome measures compared with controls. The improvement in PRO scores and rates of treatment failure, revision arthroscopic surgery, and complications was not statistically different between the groups.

Conclusion

Patients who smoke had lower PRO scores preoperatively and at the latest follow-up compared with nonsmokers. Both groups demonstrated significant improvement in all PRO scores. These results show that while hip arthroscopic surgery may still yield clinical benefit in smokers, these patients may ultimately achieve an inferior functional status. To optimize results, physicians should advise patients to cease smoking before undergoing hip arthroscopic surgery.

Prescription Opioid Use Before and After Hip Arthroscopy: A Caution to Prescribers

PURPOSE

To determine pre- and postoperative opioid utilization while identifying risk factors for prolonged postoperative opioid use following hip arthroscopy.

METHODS

All patients undergoing hip arthroscopy between 2007 and the second quarter of 2016 were identified within the Humana Inc. administrative claims database. Chronic preoperative opioid utilization was defined as filling of any opioid prescription 1 to 3 months before surgery, whereas acute preoperative opioid utilization was defined as filling any opioid prescription within 1 month of surgery. Rates of pre- and postoperative opioid utilization were calculated, and patient demographic characteristics and medical conditions associated with pre- and postoperative opioid utilization were identified.

RESULTS

Of the 1,208 patients undergoing hip arthroscopy, chronic and acute preoperative opioid utilization was observed in 24.9% and 17.3% of patients, respectively. Chronic preoperative opioid utilization was more frequently observed in obese (P < .001) patients, those ≥50 years of age (P = .002), and those with preexisting anxiety and/or depression (P < .001). In multivariate analysis, chronic preoperative opioid utilization was the strongest predictor of opioid prescription filling at 3, 6, 9, and 12 months postoperatively (odds ratio at 3 months, 18.60, 95% confidence interval, 12.41 to 28.55), whereas preexisting anxiety and/or depression and obesity were additionally identified as predictors of prolonged postoperative opioid utilization.

CONCLUSIONS

Chronic preoperative opioid utilization before hip arthroscopy is common at 24.9%. The high rate of chronic preoperative opioid utilization is particularly important considering that chronic preoperative opioid utilization is the strongest predictor of continued postoperative opioid prescription filling out to 12 months postoperatively.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Do Femoral Head Osteochondral Lesions Predict a Poor Outcome in Hip Arthroscopy Patients? A Matched Control Study With Minimum 5-Year Follow-Up

PURPOSE

To determine whether the presence of femoral head (FH) lesions affects patient-reported outcomes (PROs) of patients undergoing hip arthroscopy for labral tears.

METHODS

Data were prospectively collected and retrospectively reviewed for all patients who underwent hip arthroscopy for labral tears at our institution from April 2008 to March 2011. Patients with FH lesions were matched to those without (control) for age, body mass index, sex, and lateral center-edge angle. The inclusion criteria were FH lesions, labral tears, and minimum 5-year follow-up. The exclusion criteria were previous hip surgery, prior hip conditions, inflammatory arthritis, Workers' Compensation claims, and Tönnis grade greater than 1. PRO scores, including the modified Harris Hip Score, Non-Arthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, were collected preoperatively and postoperatively. Visual analog scale (VAS) scores for pain and patient satisfaction were recorded.

RESULTS

We matched 96 hips with FH lesions to 96 control hips. The FH group had slightly longer follow-up (71.4 months vs 67 months, P = .004). Patients with FH lesions tended to have higher-grade acetabular lesions (grade 4 acetabular labrum articular disruption and Outerbridge grade 4 acetabular lesions). All PRO scores, VAS scores, and patient satisfaction ratings were statistically improved at latest follow-up in both groups. No statistical difference in improvement (ΔPRO and ΔVAS scores) was noted between groups. However, patients with FH lesions had a higher rate of conversion to arthroplasty (32% vs 16%, P = .0027). Patients in the control group underwent more secondary arthroscopies (14% vs 5%, P = .05).

CONCLUSIONS

Finding an FH chondral lesion at arthroscopy does not necessarily portend a worse clinical outcome or conversion to total hip arthroplasty, when controlling for other variables. Patients with FH lesions were, however, found to have worse intra-articular hip pathology. When combined with these factors, patients with FH lesions had lower outcome scores and double the rate of conversion to arthroplasty than patients without them.

LEVEL OF EVIDENCE

Level III, case-control study.

Identification of a Patient Acceptable Symptomatic State Score for the International Hip Outcome Tool in People Undergoing Hip Arthroscopy

PURPOSE

To determine a Patient Acceptable Symptomatic State (PASS) score for the 33-item International Hip Outcome Tool (iHOT-33) in people undergoing hip arthroscopy for primary diagnoses of femoroacetabular impingement syndrome, acetabular labral tears, and/or ligamentum teres pathology.

METHODS

Consecutive participants underwent hip arthroscopy by a single surgeon between August 2011 and May 2016. Participants were included if they were between ages 18 and 60 years and underwent hip arthroscopy for femoroacetabular impingement syndrome, acetabular labral tears, or ligamentum teres pathology. Participants were excluded if they did not speak sufficient English to complete the iHOT-33, had evidence of hip dysplasia, had less than 2 mm of joint space on anteroposterior radiograph, or underwent subsequent total hip replacement surgery. Participants completed the iHOT-33 preoperatively and at a minimum of 1 to a maximum of 5 years postoperatively. Participants were also asked to answer yes or no to the external anchor question of "Taking into account all the activities you do during your daily life, your level of pain and also your functional impairment, are you satisfied with your current state following your surgery?" A receiver operating characteristic (ROC) curve was used to identify the PASS score. Multiple logistic regression was performed to determine if patient factors, primary preoperative diagnosis, or intraoperative findings predicted achievement of the PASS score.

RESULTS

A total of 117 participants undergoing hip arthroscopy were included: 72 women (61.1%) and 45 men (38.5%) with mean age of 36.81 years (18-59). Forty-two (35.9%) had cam morphology, 18 (15.4%) had pincer morphology, 78 (67.2%) had labral tears, and 97 (82.9%) had ligamentum teres tears. Mean time to final follow-up was 2.25 years (range, 1-5). The PASS score at a mean of 2.25 years postoperatively was 58 as determined by the cutoff threshold on the ROC curve with the lowest difference between sensitivity and specificity (area under the ROC curve 0.88; P < .01; 95% confidence interval [CI], 0.81-0.95). No factors were predictors of achievement of the PASS score in this study (P > .05), including age (odds ratio [OR], 0.71; 95% CI, 0.32-1.56), sex (OR, 1.02; 95%, CI 0.98-1.06), preoperative iHOT-33 score (OR, 1.002; 95% CI, 0.98-1.03), primary preoperative diagnosis (OR, 0.86; 95% CI, 0.53-1.40), cam morphology (OR, 1.19; 95% CI, 0.54-2.64), Pincer morphology (OR, 0.50; 95%, CI 0.18-1.38), acetabular labral tears (OR, 1.93; 95% CI, 0.88-4.26), Outerbridge grade 3-4 chondral damage (OR, 0.97; 95% CI, 0.42-2.25), and ligamentum teres pathology (OR, 0.95; 95% CI, 0.35-2.61).

CONCLUSIONS

This study reports a PASS score of 58 for the iHOT-33 at 2 years following hip arthroscopy. The PASS score will assist in assessing response to hip arthroscopy in research and clinical settings.

LEVEL OF EVIDENCE

Level II, retrospective prognostic study.

Minimum Five-Year Outcomes of Hip Arthroscopy for the Treatment of Femoroacetabular Impingement and Labral Tears in Patients with Obesity: A Match-Controlled Study

BACKGROUND

Obesity is a negative prognostic factor for various surgical procedures. The purpose of this study was to compare patients with obesity who underwent hip arthroscopy for femoroacetabular impingement and labral tears with a match-controlled group of normal-weight patients.

METHODS

Data were prospectively collected and retrospectively reviewed for patients who underwent arthroscopy between February 2008 and December 2011. Inclusion criteria were treatment for femoroacetabular impingement and labral tears and completed preoperative patient-reported outcomes and visual analog scale (VAS) for pain. Exclusion criteria were previous ipsilateral hip conditions or preoperative Tönnis grade of ≥2. Patients with obesity (body mass index [BMI] of ≥30 kg/m) were matched and were compared with normal-weight patients (BMI of 18.5 to 24.99 kg/m) using a 1:1 ratio by age at the time of the surgical procedure within 5 years, sex, acetabular Outerbridge grade (0 or 1 compared with 2, 3, or 4), and capsular treatment.

RESULTS

Of the 96 obesity cases with follow-up, 74 were pair-matched to control cases. The mean BMI was 34.3 kg/m for the obesity group and 22.7 kg/m for the control group (p < 0.0001). The mean follow-up time was 71.6 months for the obesity group and 71.3 months for the control group (p = 0.41). All mean preoperative patient-reported outcomes and VAS scores for patients without conversion to total hip arthroplasty were significantly worse in the obesity group: modified Harris hip score (p = 0.0001), Non-Arthritic Hip Score (p = 0.0001), Hip Outcome Score Sports-Specific Scale (HOS-SSS) (p = 0.015), and VAS (p = 0.01). No significant differences were observed with regard to demographic characteristics, intraoperative findings, procedures, follow-up scores, magnitudes of improvement, or secondary arthroscopy rates (p > 0.05). Both groups demonstrated significant improvements in mean outcome scores at ≥5 years (p < 0.0001). In both groups, no significant differences were detected in mean outcome scores between 2 years and ≥5 years (p > 0.05). The conversion rate to total hip arthroplasty was 29.7% for the obesity group and 14.9% for the control group (relative risk, 2.0 [95% confidence interval, 1.1 to 3.8]; p = 0.04).

CONCLUSIONS

Hip arthroscopy for the treatment of femoroacetabular impingement and labral tears in patients with obesity yielded significant improvements at ≥5 years; these results were similar to a matched group of normal-weight patients. However, patients with obesity demonstrated a twofold increased risk of conversion to total hip arthroplasty.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups

PURPOSE

To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI.

METHODS

Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB.

RESULTS

The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores.

CONCLUSIONS

The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB.

LEVEL OF EVIDENCE

Level III, retrospective matched case control study.

Prevalence and Consistency in Surgical Outcome Reporting for Femoroacetabular Impingement Syndrome: A Scoping Review

PURPOSE

The purposes of this review were (1) to collate and synthesize research studies reporting any outcome measure on both open and arthroscopic surgical treatment of femoroacetabular impingement (FAI) syndrome and (2) to report the prevalence and consistency of outcomes across the included studies.

METHODS

A computer-assisted literature search of the MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and Embase databases was conducted using keywords related to FAI syndrome and both open and arthroscopic surgical outcomes, resulting in 2,614 studies, with 163 studies involving 14,824 subjects meeting the inclusion criteria. Two authors independently reviewed study inclusion and data extraction with independent verification. The prevalence of reported outcomes was calculated and verified by separate authors.

RESULTS

Between 2004 and 2016, there has been a 2,600% increase in the publication of surgical outcome studies. Patients had a mean duration of symptoms of 27.7 ± 21.5 months before surgery. Arthroscopy was the surgical treatment used in 71% of studies. The mean final follow-up period after surgery was 32.2 ± 17.3 months. Follow-up time frames were reported in 78% of studies. Ten different patient-reported outcome measures were reported. The alpha angle was reported to be measured 42% less frequently as a surgical outcome than as a surgical indication. Surgical complications were addressed in only 53% of studies and failures in 69%. Labral pathology (91% of studies reporting) and chondral pathology (61%) were the primary coexisting pathologies reported. Clinical signs, as defined by the Warwick Agreement on FAI syndrome, were reported in fewer than 25% of studies.

CONCLUSIONS

Most FAI syndrome patients have longstanding pain and potential coexisting pathology. Patient-reported outcome measures and diagnostic imaging are the most frequently reported outcomes. Measures of hip strength and range of motion are under-reported. It is unclear whether the inconsistency in reporting is because of lack of measurement or lack of reporting of specific outcomes in these studies. Current surgical outcomes are limited to mid-term surgical follow-up time frames and inconsistent outcome reporting.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I through IV studies.

Hip Arthroscopic Surgery for Femoroacetabular Impingement With Capsular Management: Factors Associated With Achieving Clinically Significant Outcomes

BACKGROUND

There has been increasing interest in defining clinically meaningful outcomes in patient reported outcomes following orthopaedic surgery. Little is known about the factors associated with clinically meaningful outcomes after hip arthroscopy for femoroacetabular impingement.

STUDY DESIGN

Case-control study; Level of evidence, 3.

PURPOSE

To report on a large, prospectively collected consecutive series of patients who underwent comprehensive arthroscopic treatment of femoroacetabular impingement (FAI) and capsular management with greater than 2-year follow-up. The objectives were to determine (1) what percentage of patients achieve clinically significant outcomes after hip arthroscopic surgery for FAI as determined by the minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) and (2) what factors are associated with achieving the MCID and PASS.

METHODS

Data from an institutional repository of consecutive patients undergoing primary hip arthroscopic surgery with routine capsular closure for FAI that had failed nonsurgical management between January 2012 and January 2014 were prospectively collected and analyzed. Of 474 patients during the enrollment period, 386 (81.4%) patients were available for a minimum 2-year follow-up. Demographics, radiographic measurements, intraoperative characteristics, and patient-reported outcome scores were collected. The primary outcome measure was achieving published thresholds for the MCID and PASS for the Hip Outcome Score (HOS)-Activities of Daily Living (ADL) in patients with FAI. The HOS-Sport-Specific Subscale (SSS), complications, and reoperations were secondary outcome measures. Multivariate regression analyses were conducted to identify factors associated with achieving the MCID and PASS.

RESULTS

At a minimum of 2-year follow-up, the patients had statistically significant improvements in all patient-reported outcomes (HOS-ADL, HOS-SSS, and modified Harris Hip Score [mHHS]; P < .001 for all), with a 1.2% rate of revision hip arthroscopic surgery and 1.7% rate of conversion to total hip arthroplasty. The MCID was achieved by 78.8% of patients for the HOS-ADL, and the PASS was achieved by 62.5% for the HOS-ADL. Younger age ( P = .008), Tönnis grade 0 ( P = .022), and lower preoperative HOS-ADL score ( P < .001) were associated with successfully achieving the MCID for the HOS-ADL. Younger age ( P < .001), larger medial joint space width ( P = .028), and higher preoperative HOS-ADL score ( P < .001) were associated with achieving the PASS for the HOS-ADL. Younger age ( P < .001), lower body mass index ( P = .006), non-workers' compensation status ( P = .020), and lower preoperative HOS-SSS score ( P < .001) were associated with achieving the MCID for the HOS-SSS. Younger age ( P = .001), Tönnis grade 0 ( P = .014), running ( P = .008), and higher preoperative HOS-SSS score ( P < .001) were associated with achieving the PASS for the HOS-SSS. Overall, 49.4% of patients achieved all 4 clinically significant outcomes: both the MCID and PASS for the HOS-ADL and HOS-SSS.

CONCLUSION

The majority of patients undergoing hip arthroscopic surgery with routine capsular closure for FAI experienced clinically significant outcomes that met the MCID or PASS criteria, with low rates of revision and conversion to total hip arthroplasty. Factors associated with these successful outcomes on multivariate analyses included younger age with a normal joint space. Patients with lower preoperative HOS scores were more likely to achieve the MCID, whereas patients with higher preoperative HOS scores were more likely to achieve the PASS.

Results of hip arthroscopy in patients with MRI diagnosis of subchondral cysts-a case series

The aim of this article is to examine the results of arthroscopic management of patients with labral pathology who have preoperative magnetic resonance images (MRIs) demonstrating subchondral cysts. This institution's database was searched for patients who underwent hip arthroscopy and had subchondral cysts on MRI and >2-year follow-up. Exclusion criteria included previous hip surgery, Tönnis grade >1, inflammatory arthritis, Perthes, slipped capital femoral epiphysis or abductor repair. Patient-reported outcome (PRO) scores including visual analog scale, modified Harris hip score (mHHS), non-arthritic hip score and hip outcome score sports-specific subscale (HOS-SSS) were gathered preoperatively, at 3 months, and annually thereafter. The change in PRO scores was compared with the minimally clinical important difference (MCID) to quantify improvement. Sixty-nine patients were eligible for this study, of which 65 (94%) had >2-year follow-up. All PROs were significantly improved at latest follow-up (P < 0.001). Mean patient satisfaction was 7.2. There was no correlation between Outerbridge grade III or IV cartilage damage noted during arthroscopy and subchondral femoral and acetabular cysts noted on MRI. Seventeen patients required reoperation [13 total hip arthroplasty (THAs) and 4 revision arthroscopies]. Patients with femoral subchondral cysts converted to THA 36% of the time. MCIDs for mHHS and HOS-SSS were surpassed by 63% and 68% of patients, respectively. Hip arthroscopies performed on patients with subchondral cysts present on preoperative MRI should be approached with caution. The rate of conversion to hip arthroplasty appears to be higher than that reported in the literature for patients who undergo arthroscopy without preoperative subchondral cysts. For patients who did not require hip arthroplasty or revision arthroscopy, patients demonstrated significant improvement in symptoms compared with the preoperative state.

Clinical Outcomes of Hip Arthroscopic Surgery in Patients With Femoral Retroversion: A Matched Study to Patients With Normal Femoral Anteversion

Background:

Femoral retroversion has been noted as a possible risk factor for poor clinical results after hip arthroscopic surgery.

Purpose:

To compare the outcomes of the arthroscopic treatment of hip abnormalities in patients with femoral retroversion to patients with femoral anteversion between 10° and 20°.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Between November 2011 and September 2013, 790 hip arthroscopic procedures were performed at a single institution. Of these, 59 hips (7.5%) were located in patients with femoral version ≤0°, calculated using preoperative magnetic resonance imaging. These patients were pair matched, based on body mass index ±5 kg/m², age ±5 years, and Tönnis grade, with 59 patients with femoral anteversion between 10° and 20°. Exclusion criteria included Perthes disease, inflammatory arthritis, slipped capital femoral epiphysis, previous hip surgery, abductor repair, lateral center-edge angle <20°, Tönnis grade >1, and acetabular profunda or protrusio. Patient-reported outcomes (PROs) were recorded preoperatively, at 3 months postoperatively, and annually thereafter. The PROs utilized were the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), and Hip Outcome Score–Sports-Specific Subscale (HOS-SSS). The visual analog scale (VAS) was collected to assess the patients’ pain; patient satisfaction scores (0-10) were also collected. Radiographs were collected at the above time intervals as well.

Results:

Two patients from the control group and 1 patient from the retroverted group required total hip arthroplasty at a mean 19.5 and 26.3 months, respectively. Both groups demonstrated significant improvement from their preoperative state in all PRO and VAS scores (P < .001). No differences in preoperative, postoperative, or change in PRO and VAS scores between the groups were noted.

Conclusion:

Patients with femoral retroversion reported similar outcomes compared to patients with normal femoral version when undergoing hip arthroscopic surgery. Both groups had similar improvements from the preoperative state.

Fluoroscopy Learning Curve in Hip Arthroscopy-A Single Surgeon's Experience

PURPOSE

To determine if (1) absorbed radiation dose and (2) fluoroscopy time decreased with experience over the first 100 cases of a single surgeon's hip arthroscopy practice.

METHODS

Subjects who underwent hip arthroscopy for symptomatic femoroacetabular impingement and labral injury were eligible for analysis. Inclusion criteria included the first 100 subjects who underwent hip arthroscopy by a single surgeon (December 2013 to December 2014). Subject demographics, procedure details, fluoroscopy absorbed dose (milligray [mGy]), and time were recorded. Subjects were categorized by date of surgery to one of 4 possible groups (25 per group). One-way analysis of variance was used to determine if a significant difference in dose (mGy) or time was present between groups. Simple linear regression analysis was performed to determine the relation between case number and both radiation dose and fluoroscopy time.

RESULTS

Subjects underwent labral repair (n = 93), cam osteoplasty (n = 90), and pincer acetabuloplasty (n = 65). There was a significant (P < .001 for both) linear regression between case number and both radiation dose and fluoroscopy time. A significant difference in mGy was observed between groups, group 1 the highest and group 4 the lowest amounts of radiation (P = .003). Comparing individual groups, group 4 was found to have a significantly lower amount of radiation than group 1 (P = .002), though it was not significantly lower than that of group 2 (P = .09) or group 3 (P = .08). A significant difference in fluoroscopy time was observed between groups, group 1 the highest and group 4 the lowest times (P = .05). Comparing individual groups, group 4 was found to have a significantly lower fluoroscopy time than group 1 (P = .039). Correction for weight, height, and body mass index all revealed the same findings: significant (P < .05) differences in both dose and time across groups.

CONCLUSIONS

The absorbed dose of radiation and fluoroscopy time decreased significantly over the first 100 cases of a single surgeon's hip arthroscopy practice learning curve.

LEVEL OF EVIDENCE

Level IV, therapeutic, retrospective, noncomparative case series.

The Influence of Body Mass Index on Outcomes After Hip Arthroscopic Surgery With Capsular Plication for the Treatment of Femoroacetabular Impingement

BACKGROUND

It remains unknown how variations in body mass index (BMI) influence outcomes after primary hip arthroscopic surgery with capsular plication for femoroacetabular impingement (FAI).

PURPOSE

To evaluate the effect that abnormal BMI (namely, overweight, obese, morbidly obese, and underweight) versus normal weight has on patient-reported clinical outcomes more than 2 years postoperatively from primary hip arthroscopic surgery with capsular plication by a single surgeon.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

A clinical repository containing patients undergoing primary hip arthroscopic surgery for FAI between January 1, 2012, and January 1, 2014, with a minimum 2-year follow-up was queried. Outcome measures included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports, modified Harris Hip Score (mHHS), visual analog scale (VAS) for pain; satisfaction, and Patient Acceptable Symptomatic State (PASS) for the HOS-ADL; scores were collected preoperatively and at 3 months, 1 year, and minimum 2 years postoperatively. Included patients were segregated by preoperative BMI into the following categories: underweight (<18.5 kg/m²), normal (18.5-24.9 kg/m²), overweight (25.0-29.9 kg/m²), obese (30.0-34.9 kg/m²), and morbidly obese (≥35.0 kg/m²). A multivariate logistic regression model controlling for patient demographics and disease severity was used to identify independent associations between BMI categories and outcomes. A Bonferroni adjustment lowered the threshold for significance to P < .01.

RESULTS

There were 409 hips in 381 patients appropriate for study inclusion: 7 underweight, 197 normal BMI, 130 overweight, 31 obese, and 16 morbidly obese. The mean age was 33.1 ± 12.1 years, with 232 (61%) female patients. At 2 years postoperatively, significant differences in the trend among HOS-ADL, HOS-Sports, and mHHS scores were evident, with normal BMI patients, followed by underweight patients, demonstrating greater scores than their overweight, obese, and morbidly obese counterparts. Obese patients demonstrated lower satisfaction scores than normal BMI patients. Overweight, obese, and morbidly obese patients had lower improvements in VAS pain scores compared with normal BMI patients. Increasing BMI (not subdivided into the 5 BMI categories) was associated with a higher infection risk (mean BMI for infections: 32.3 ± 9.8 kg/m² vs mean BMI for noninfections: 25.2 ± 4.8 kg/m²; P = .0035). However, with multivariate analysis, no significant differences in patient clinical outcomes between the BMI categories met the threshold for significance. Among obese patients (BMI ≥30.0 kg/m²), no specific risk factors were found to be significantly associated with decreases in the change in VAS, HOS-ADL, HOS-Sports, mHHS, satisfaction, or PASS for the HOS-ADL scores. However, because of the small cohort sizes at the extremes of the BMI categories, this analysis may have been underpowered to identify a significant difference in underweight or morbidly obese patients.

CONCLUSION

In the current cohort, there were multiple potential confounding variables, and while some clinical differences were observed initially (higher HOS-ADL, HOS-Sports, and mHHS scores for normal BMI patients than overweight and obese patients at 2 years postoperatively; lower satisfaction scores for obese patients than normal BMI patients; and lower improvement in VAS pain scores for overweight, obese, and morbidly obese patients when compared with normal BMI patients), after multivariate analysis, no associations were observed between BMI and clinical outcomes after hip arthroscopic surgery with capsular plication for FAI.

Ability to return to work without restrictions in workers compensation patients undergoing hip arthroscopy

The purpose of this study was to investigate the ability of worker’s compensation (WC) patients to return to work without restrictions after hip arthroscopy. Twenty-nine WC patients along with age and gender matched controls who underwent hip arthroscopy were retrospectively reviewed after achieving maximum medical improvement (MMI) status at minimum 1 year postoperatively. Patient demographic factors were evaluated, along with the Hip Outcome Score Activities of Daily Living and Sports-Specific subscales, and the modified Harris Hip Score (mHHS). The majority of WC patients were able to return to work without restrictions after reaching MMI (20/29, 69.0%). WC patients who failed to return to work without restrictions had a prolonged time from injury to surgery (3.01 ± 2.16 months versus 6.36 ± 4.16 months; P = 0.0079), more concomitant orthopedic injuries (4/20, 20.0% versus 9/9, 100%; P = 0.0001), and higher body mass index (BMI) (26.61 ± 3.52 versus 29.54 ± 3.43; P = 0.047) than those who returned to work without restrictions. WC patients had significant improvement of patient-reported outcome scores following hip arthroscopy (P < 0.0001), but WC patients who returned to work without restrictions had higher scores than those who failed to do so (HOD-ADL: P < 0.0001; HOS-SS: P = 0.004; mHHS: P = 0.009). The majority of WC patients are able to return to work without restrictions when they reach MMI status following hip arthroscopy. Factors associated with failure to return to work without restrictions include prolonged time course between injury and surgical treatment, concomitant orthopaedic injuries, and a higher BMI. Level III, retrospective case-control study

Outcome of Hip Impingement Surgery: Does Generalized Joint Hypermobility Matter?

BACKGROUND

Generalized joint hypermobility (JH) might negatively influence the results of surgical femoroacetabular impingement (FAI) treatment, as JH has been linked to musculoskeletal pain and injury incidence in athletes. JH may also be associated with worse outcomes of FAI surgery in thin females.

PURPOSE

To (1) determine the results of FAI surgery at a minimum 2-year follow-up by means of patient-reported outcome measures (PROMs) and failure rates, (2) assess the prevalence of JH in FAI patients and its effect on outcomes, and (3) identify other risk factors associated with treatment failure.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

We included 232 consecutive patients (118 females; mean age, 36 years) with 244 hips surgically treated for symptomatic FAI between 2010 and 2012. All patients completed different PROMs preoperatively and at a mean follow-up of 3.7 years. Satisfaction questions were used to define subjective failure (answering any of the 2 subjective questions with dissatisfied/ very dissatisfied and/or didn't help/ made things worse). Conversion to total hip replacement (THR) was defined as objective failure. JH was assessed using the Beighton score.

RESULTS

All PROM values significantly ( P < .001) improved from preoperative measurement to follow-up (Oxford Hip Score: 33.8 to 42.4; University of California at Los Angeles Activity Scale: 6.3 to 7.3; EuroQol-5 Dimension Index: 0.58 to 0.80). Overall, 34% of patients scored ≥4 on the Beighton score, and 18% scored ≥6, indicating generalized JH. Eleven hips (4.7%) objectively failed and were converted to THR. Twenty-four patients (10.3%) were considered as subjective failures. No predictive risk factors were identified for subjective failure. Tönnis grade significantly ( P < .001) predicted objective failure (odds ratio, 13; 95% CI, 4-45). There was a weak inverse association ( r = -0.16 to -0.30) between Beighton scores and preoperative PROM values. There were no significant associations between Beighton scores and postoperative PROM values or subjective failure rates, but patients who objectively failed had lower Beighton scores than did nonfailures (1.6 vs 2.6; P = .049).

CONCLUSION

FAI surgery yielded favorable outcomes at short- to midterm follow-up. JH as assessed by the Beighton score was not consistently associated with subjective and objective results. Joint degeneration was the most important risk factor for conversion to THR. Although statistical significance was not reached, female patients with no joint degeneration, only mild FAI deformity, and higher Oxford scores at the time of surgery seemed to be at increased risk for subjective dissatisfaction.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.

Patient Satisfaction Reporting for the Treatment of Femoroacetabular Impingement

PURPOSE

The purpose of this study was to evaluate how patient satisfaction after surgical femoroacetabular impingement (FAI) treatment is measured and reported in the current evidence base.

METHODS

A review of the MEDLINE database was performed. Clinical outcome studies of FAI that reported a measure of patient satisfaction were included. Patient demographics, clinical outcome scores, and patient satisfaction measures were extracted. The NewCastle Ottawa Scale (NOS) was used to grade quality. Statistical analysis was primarily descriptive.

RESULTS

Twenty-six studies met inclusion criteria; the mean NOS score among included studies was 5.7. Most studies were level 3 or 4 (n = 25, 96.1%). A 0 to 10 numeric scale, described by some studies as a visual analog scale, was the most commonly used method to assess satisfaction (n = 21; 80.8%), and mean reported scores ranged from 6.8 to 9.2 out of 10. Four studies (15.4%) used an ordinal scale, and 1 study (3.8%) used willingness to undergo surgery again as the measure of satisfaction. None of the included studies assessed preoperative satisfaction or patient expectation. Pooled cohort analysis was limited by significant overlapping study populations. Predictors of patients' satisfaction identified in included studies were presence of arthritis and postoperative outcome scores.

CONCLUSIONS

Patient satisfaction was not uniformly assessed in the literature. Most studies used a 0- to 10-point satisfaction scale, but none distinguished between the process of care and the outcome of care. Although satisfaction scores were generally high, the quality of the methodologies in the studies that reported satisfaction was low, and the studies likely included overlapping patient populations. More work needs to be done to develop standardized ways for assessing patient satisfaction after arthroscopic hip surgery and other procedures in orthopaedic sports medicine.

LEVEL OF EVIDENCE

Level III, systematic review of Level III studies.

Use of Hip Arthroscopy and Risk of Conversion to Total Hip Arthroplasty: A Population-Based Analysis

PURPOSE

To use population-level data to (1) evaluate the conversion rate of total hip arthroplasty (THA) within 2 years of hip arthroscopy and (2) assess the influence of age, arthritis, and obesity on the rate of conversion to THA.

METHODS

We used the State Ambulatory Surgery Databases and State Inpatient Databases for California and Florida from 2005 through 2012, which contain 100% of patient visits. Hip arthroscopy patients were tracked for subsequent primary THA within 2 years. Out-of-state patients and patients with less than 2 years follow-up were excluded. Multivariate analysis identified risks for subsequent hip arthroplasty after arthroscopy.

RESULTS

We identified 7,351 patients who underwent hip arthroscopy with 2 years follow-up. The mean age was 43.9 ± 13.7 years, and 58.8% were female patients. Overall, 11.7% of patients underwent THA conversion within 2 years. The conversion rate was lowest in patients aged younger than 40 years (3.0%) and highest in the 60- to 69-year-old group (35.0%) (P < .001). We found an increased risk of THA conversion in older patients and in patients with osteoarthritis or obesity at the time of hip arthroscopy. Patients treated at high-volume hip arthroscopy centers had a lower THA conversion rate than those treated at low-volume centers (15.1% v 9.7%, P < .001).

CONCLUSIONS

Hip arthroscopy is performed in patients of various ages, including middle-aged and elderly patients. Older patients have a higher rate of conversion to THA, as do patients with osteoarthritis or obesity.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

A Comparison of Supine and Lateral Decubitus Positions for Hip Arthroscopy: A Systematic Review of Outcomes and Complications

PURPOSE

This systematic review examines outcomes and risk profiles of the hip arthroscopy in the supine versus lateral decubitus positions to elucidate any superiority of one approach over the other.

METHODS

Three databases (Embase, PubMed, and Medline) were searched for studies that addressed hip arthroscopy performed in either position, and were subsequently screened by two reviewers with data abstracted in duplicate.

RESULTS

Similar outcomes were observed. Supine studies showed a greater mean postoperative improvement for modified Harris hip score (33.74), visual analog scale (-3.99), nonarthritic hip score (29.61), Harris hip score (35.73), and hip outcome score (31.4). Lateral decubitus studies showed greater improvement using the Western Ontario and McMaster University Osteoarthritis (14.76) score. Supine studies reported more neuropraxic injuries (2.06% v 0.47%), labral penetration (0.65% v 0%), and heterotopic ossification (0.21% v 0%). Lateral decubitus studies reported more fluid extravasation (0.21% v 0.05%) and missed loose bodies (0.08% v 0.01%). Similar rates of revision (1.8% lateral, 1.4% supine) and conversion to open procedures (2.6% in lateral, 2.0% in supine) were also identified.

CONCLUSIONS

Because of quality of evidence, direct comparisons are currently limited; however, the supine position is associated with more neuropraxic injuries, labral penetration, and heterotopic ossification, whereas lateral decubitus has increased risk of fluid extravasation and missed loose bodies. At this time, no evidence exists to establish superiority of one position.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II, III, and IV studies.

Hip arthroscopy in obese, a successful combination?

Discussion persists about the outcome and results of hip arthroscopy in obese patients. Hip arthroscopy gained popularity over time. A current discussion is if obese patients can reach similar results after surgery compared with non-obese. To our knowledge, this is the first systematic review of literature about hip arthroscopy and obesity. We searched the Pubmed/Medline databases for literature and included three studies that compared the outcome of hip arthroscopy between different BMI groups. We extracted and pooled the data. For continues data a weighted mean difference was calculated, for dichotomous variables a weighted odds ratio (OR) was calculated using Review Software Manager. Heterogeneity of the included studies was calculated using I² statistics. Data were extracted from two studies. In the Obese group, there was significant more conversion to total hip replacement or resurfacing hip replacement (OR = 2.21, 95% CI 1.07–4.56) and more re-arthroscopy (OR = 4.68, 95% CI 1.41–15.45). Any reoperation occurred more often in the obese group (OR = 2.87, 95% CI 1.53–5.38). In the Non Arthritic Hip Score obese scored lower than the non-Obese group [10.9 (−14,6 to 7.1)]. For the modified Harris Hip Score the score is − 6,6, according to the MCID this difference is clinically relevant. For both scores obese show lower outcomes but similar improvement after hip arthroscopy. Regarding a higher chance of needing a re-operation and lower subjective outcome scores obesity appears to have a negative influence on the outcome of hip arthroscopy.