Mental Health Medication Use Correlates with Poor Outcome After Femoroacetabular Impingement Surgery in a Military Population

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

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

RESULTS

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

CONCLUSION

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

IV, systematic review of Level II-IV studies.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Periacetabular Osteotomy in United States Military Personnel: Results From an Interservice Hip Preservation Practice

Background:

Untreated or residual developmental dysplasia of the hip may cause significant morbidity. Periacetabular osteotomy (PAO) allows for surgical reorientation of the acetabulum but requires a significant recovery period. Because of the physical demands of active military service, hip dysplasia or its treatment with PAO may cause a significant impact on the careers of affected personnel.

Purpose:

To measure the impact of symptomatic acetabular dysplasia and its treatment with PAO on the physical readiness of personnel in the United States Armed Forces.

Study Design:

Case series; Level of evidence, 4.

Methods:

Records from an interservice hip-preservation practice were reviewed for all patients who underwent PAO while on active duty from January 2014 through April 2017. Collected information included branch of service, military occupation, preoperative duty restrictions related to the hip, and concomitant surgical procedures. Patients were evaluated for a minimum of 24 months and assessed for their time to return to duty, continued duty restrictions, and referrals to the medical evaluation board.

Results:

Twenty patients (15 female, 5 male) underwent a PAO while on active duty during the period assessed. The mean patient age at surgery was 25.9 years, and the mean follow-up was 3.3 years (range, 2.3-5.4 years). In the 6 months preceding surgery, 94% of the 17 patients with available records were on duty restrictions specific to their hip (14 temporary, 2 permanent). After PAO, 35% of patients (n = 7) returned to full duty and 85% were able to remain on active duty (n = 12) or complete their military service commitments (n = 5) without noted medical disability. Three patients were medically discharged after PAO, with 1 patient referred due to hip pathology.

Conclusion:

Acetabular dysplasia significantly affects physical readiness in affected servicemembers, with 94% requiring duty restrictions. PAO allowed 85% of patients to return to military service, and 1 in 3 were able to return to full duty.

Are We Able to Determine Differences in Outcomes Between Male and Female Servicemembers Undergoing Hip Arthroscopy? A Systematic Review

Background:

Female servicemembers sustain higher rates of lower extremity injuries as compared with their male counterparts. This can include intra-articular pathology in the hip. Female patients are considered to have worse outcomes after hip arthroscopy for femoroacetabular impingement and for hip labral repair.

Purpose:

To (1) compare published rates of hip arthroscopy between male and female military servicemembers and (2) determine if there are any sex-based differences in outcomes after hip arthroscopy in the military.

Study Design:

Systematic review; Level of evidence, 3.

Methods:

We reviewed the literature published from January 1, 2000, through December 31, 2020, to identify studies in which hip arthroscopy was performed in military personnel. Clinical trials and cohort studies were included. The proportion of women within each cohort was identified, and results of any between-sex analyses were reported.

Results:

Identified were 11 studies that met established criteria. Studies included 2481 patients, 970 (39.1%) of whom were women. Surgery occurred between January 1998 and March 2018. Despite women accounting for approximately 15% of the active-duty military force, they represented 39.1% (range, 25.7%-57.6%) of patients undergoing hip arthroscopy. In most cases, there were no differences in self-reported outcomes (pain, disability, and physical function), return to duty, or medical disability status based on sex.

Conclusion:

Women account for approximately 15% of the military, but they made up 40% of patients undergoing hip arthroscopy. Outcomes were not different between the sexes; however, definitive conclusions were limited by the heterogeneity of outcomes, missing data, lack of sex-specific subgroup analyses, and zero studies with sex differences as the primary outcome. A proper understanding of sex-specific outcomes after hip arthroscopy will require a paradigm shift in the design and reporting of trials in the military health system.

Psychological Healthcare Burden Lessens After Hip Arthroscopy for Those With Comorbid Depression or Anxiety

Purpose

In this study, we investigated whether patients undergoing arthroscopic treatment of femoral acetabular impingement syndrome (FAIS) seek health care for treatment of comorbid depression and anxiety in the year following hip arthroscopy.

Methods

Using the Truven Health Marketscan database, FAIS patients who underwent hip arthroscopy between January 2009 and December 2016 were identified. Claims related to depression or anxiety filed during the year before surgery were required for inclusion. Using claims for pharmaceutical and psychological therapy treatments for mental health disorders, four groups of patients were analyzed on the basis of preoperative anxiety/depression treatment: medication only, therapy only, medication + therapy, and no treatment. Number of opioid pain prescriptions within 180 days prior to surgery and >90 days after hip arthroscopy were also compared.

Results

Depression and anxiety claims were identified in 5,208/14,830 (35.1%) patients. Preoperative treatment for depression and anxiety included medication only (n = 648, 12.4%), therapy only (n = 899, 17.3%), medication + therapy (n = 252, 4.8%), and no treatment (n = 3,409, 65.5%). Of the 900 patients who filled an anxiety/depression-related prescription prior to surgery, 422 (46.9%) patients did not fill a similar prescription in the postoperative year. Of the 1,151 patients receiving anxiety/depression-related therapy prior to surgery, 549 (47.7%) did not receive therapy in the postoperative year. Preoperative opioid prescriptions were filled for 393 patients (60.6%) in medication-only group, 275 (30.6%) in therapy-only group, 156 (61.9%) in medication + therapy group, and 1,059 (31.1%) in the group receiving no treatment. Opioid prescriptions >90 days postoperatively were filled for 330 (50.9%), 225 (25.0%), 120 (47.6%), and 861 (25.3%) patients, respectively.

Conclusion

Hip arthroscopy for FAIS is associated with a decreased postoperative use of health care resources for the treatment of depression and anxiety. Clinicians should also be aware of the potential interplay between preoperative psychotropic medication use and prolonged opioid use when counseling patients.

Level of Evidence

IV, therapeutic case series.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Low mental health scores are associated with worse patient-reported outcomes and difficulty with return to work and sport after distal biceps repair

Background

Most patients have successful outcomes with minimal limitations after distal biceps repair, but a minority continues experiencing functional constraints. We hypothesize that low scores on a validated mental health measure correlate with worse patient-reported outcomes and increased difficulty with return to work and sport.

Methods

We conducted a retrospective review of a consecutive series of patients who underwent distal biceps repair with a single-incision cortical button technique and immediate mobilization. Patient-reported outcome data were available at 1 year or later for 33 (85%) patients. The primary outcomes were American Shoulder and Elbow Surgeons-Elbow (ASES-E) score, Single Assessment Numeric Evaluation score, Visual Analog Scale for pain, Disabilities of the Arm, Shoulder and Hand Score (QuickDASH), and Veterans RAND 12 (VR-12) quality-of-life assessment.

Results

All patients were male, with a median age of 49 years (range, 28-65). None had reruptures, and 1 (3%) had superficial wound dehiscence that healed without further surgery. Eleven (33%) had postoperative neuropraxia, 6 of which resolved completely. At latest follow-up, the median Visual Analog Scale was 0 (range, 0-5; mean, 1), and median ASES-E functional score was 36 (range, 24-36; mean, 34). Median Single Assessment Numeric Evaluation score was 92 (range, 41-100). The median QuickDASH was 5 (range, 0-50; mean, 11). More than half of the patients with VR-12 mental component score (MCS) < 50 (5 of 9, 56%) reported difficulty with work activities, compared with 4% (1 of 24) of patients with an MCS ≥ 50 (P = .001). Most patients (8 of 9, 89%) with an MCS < 50 also reported difficulty with return to sporting activities, compared with only 8% (2 of 24) of patients with MCS ≥ 50 (P < .0001). Patients with an MCS < 50 (n = 9) had significantly worse ASES-E functional scores (median, 34; range, 27-36) and QuickDASH scores (median 23, range 0-43), compared with those with an MCS ≥ 50 (ASES-E: median, 36; range, 24-36; P = .033; QuickDASH: median, 2; range, 0-50; P = .026). Most patients (17 of 24, 71%) with MCS ≥ 50 had a perfect score of 36 on the ASES-E functional outcome score, compared with only 22% (2 of 9) among patients with MCS < 50.

Conclusion

Patients who undergo distal biceps repair show excellent functional patient-reported outcomes at 1-year and later follow-up. Lower scores on the VR-12 MCS are associated with worse patient-reported outcome scores and difficulty with return to work and sporting activities.

The influence of pain catastrophizing and central sensitization on the reported pain after hip arthroscopy

PURPOSE

This study was conducted to investigate whether the pain catastrophizing scale (PCS) and the central sensitization inventory (CSI) are predictive factors for the reported pain after hip arthroscopy.

METHODS

A total of 37 patients undergoing hip arthroscopy for femoroacetabular impingement syndrome and labral tears were prospectively enrolled. All patients completed the PCS and CSI before hip arthroscopy. Postoperative pain was measured with the numeric rating scale (NRS) weekly the first 12 weeks after surgery by electronic diary.

RESULTS

At baseline, univariate analyses showed that both the CSI and PCS were significantly associated with the NRS outcome (p < 0.01). During 12 weeks follow-up, a significant decrease on the NRS was observed (p < 0.01). Univariate analyses showed that both the CSI and PCS were significantly associated with the NRS during follow-up. Multivariate mixed model analysis showed that only the PCS remained significantly associated with the NRS outcome with a ß of 0.07 (95% CI 0.03-0.11, p < 0.01).

CONCLUSION

Results indicate that both the PCS and CSI are associated with the reported postoperative pain after hip arthroscopy. The PCS and CSI may be useful in daily practice to identify patients that possibly benefit from pain catastrophizing reduction therapy (e.g. counseling) prior to surgery.

LEVEL OF EVIDENCE

IV.

Factors associated with high pain catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome

The purpose of this study was to determine if physical, mental health and patient-specific factors are associated with increased Pain Catastrophizing in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Patients who underwent primary hip arthroscopy for FAIS were retrospectively analyzed. Patients were included if they completed a standard pre-operative questionnaire which included the Pain Catastrophizing Scale (PCS), VAS and 12-Item Short Form Survey (SF-12) Physical and Mental Composite Scores. Patient-specific variables including age, gender, BMI, tobacco use, number of allergies, pre-operative opioid use and diagnosis of depression or anxiety were recorded. Multiple linear regression was performed to assess for a relationship between physical and mental health scores, patient-specific variables, and a 'High Catastrophizing' PCS score. One-hundred and sixty-eight patients were included in this study. Patients with a PCS score of 22 or above were categorized as 'High Catastrophizing'. The variables included in the multiple linear regression model statistically significantly predicted high pain catastrophizing, F(10,149) = 4.75, P < 0.001, R ² = 0.4. SF-12 Physical and Mental Composite Scores and a mental health illness diagnosis added statistically significantly to the prediction, P < 0.005. Pre-operative hip arthroscopy patients with better general physical and mental health, as measured by the SF-12, and those without mental health illness are less likely to having higher pain catastrophizing scores. Age, gender, BMI, visual analog pain scale (VAS), tobacco use, number of allergies and pre-operative opioid use were not independently associated with elevated pain catastrophizing scores. These findings may be helpful when interpreting PCS scores and counseling patients prior to arthroscopic hip surgery.

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

BACKGROUND

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

PURPOSE

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

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

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

RESULTS

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

CONCLUSION

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

REGISTRATION

CRD42019124836 (PROSPERO).

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

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

The Resilient Athlete: Lessons Learned in the Military

Resilience, the capacity to recover from a setback or adversity, is a concept that has received considerable recent attention. An individual's resilience predicts their life trajectory following stressful events and this has increasingly been shown in a wide variety of applications. Our understanding of the degree to which we can modify our resilience, and the optimal means to do so, remains in its infancy. The US military has embraced extensive efforts to quantify and build resilience in service members in an effort to preserve the fighting force. We specifically look at the understanding of resilience as it relates to the athletes in terms of competition and return from injury. This article explores the concept of resilience, the efforts to build resilience, lessons learned from the military and applications of the resilience concept to surgical and trauma patients.

Musculoskeletal Injuries and United States Army Readiness Part I: Overview of Injuries and their Strategic Impact

Introduction

Noncombat injuries (“injuries”) greatly impact soldier health and United States (U.S.) Army readiness; they are the leading cause of outpatient medical encounters (more than two million annually) among active component (AC) soldiers. Noncombat musculoskeletal injuries (“MSKIs”) may account for nearly 60% of soldiers’ limited duty days and 65% of soldiers who cannot deploy for medical reasons. Injuries primarily affect readiness through increased limited duty days, decreased deployability rates, and increased medical separation rates. MSKIs are also responsible for exorbitant medical costs to the U.S. government, including service-connected disability compensation. A significant subset of soldiers develops chronic pain or long-term disability after injury; this may increase their risk for chronic disease or secondary health deficits potentially associated with MSKIs. The authors will review trends in U.S. Army MSKI rates, summarize MSKI readiness-related impacts, and highlight the importance of standardizing surveillance approaches, including injury definitions used in injury surveillance.

Materials/Methods

This review summarizes current reports and U.S. Department of Defense internal policy documents. MSKIs are defined as musculoskeletal disorders resulting from mechanical energy transfer, including traumatic and overuse injuries, which may cause pain and/or limit function. This review focuses on various U.S. Army populations, based on setting, sex, and age; the review excludes combat or battle injuries.

Results

More than half of all AC soldiers sustained at least one injury (MSKI or non-MSKI) in 2017. Overuse injuries comprise at least 70% of all injuries among AC soldiers. Female soldiers are at greater risk for MSKI than men. Female soldiers’ aerobic and muscular fitness performances are typically lower than men’s performances, which could account for their higher injury rates. Older soldiers are at greater injury risk than younger soldiers. Soldiers in noncombat arms units tend to have higher incidences of reported MSKIs, more limited duty days, and higher rates of limited duty days for chronic MSKIs than soldiers in combat arms units. MSKIs account for 65% of medically nondeployable AC soldiers. At any time, 4% of AC soldiers cannot deploy because of MSKIs. Once deployed, nonbattle injuries accounted for approximately 30% of all medical evacuations, and were the largest category of soldier evacuations from both recent major combat theaters (Iraq and Afghanistan). More than 85% of service members medically evacuated for MSKIs failed to return to the theater. MSKIs factored into (1) nearly 70% of medical disability discharges across the Army from 2011 through 2016 and (2) more than 90% of disability discharges within enlisted soldiers’ first year of service from 2010 to 2015. MSKI-related, service-connected (SC) disabilities account for 44% of all SC disabilities (more than any other body system) among compensated U.S. Global War on Terrorism veterans.

Conclusions

MSKIs significantly impact soldier health and U.S. Army readiness. MSKIs also figure prominently in medical disability discharges and long-term, service-connected disability costs. MSKI patterns and trends vary between trainees and soldiers in operational units and among military occupations and types of operational units. Coordinated injury surveillance efforts are needed to provide standardized metrics and accurately measure temporal changes in injury rates.

Application of Machine Learning for Predicting Clinically Meaningful Outcome After Arthroscopic Femoroacetabular Impingement Surgery

BACKGROUND

Hip arthroscopy has become an important tool for surgical treatment of intra-articular hip pathology. Predictive models for clinically meaningful outcomes in patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) are unknown.

PURPOSE

To apply a machine learning model to determine preoperative variables predictive for achieving the minimal clinically important difference (MCID) at 2 years after hip arthroscopy for FAIS.

STUDY DESIGN

Case-control study; Level of evidence, 3.

METHODS

Data were analyzed for patients who underwent hip arthroscopy for FAIS by a high-volume fellowship-trained surgeon between January 2012 and July 2016. The MCID cutoffs for the Hip Outcome Score-Activities of Daily Living (HOS-ADL), HOS-Sport Specific (HOS-SS), and modified Harris Hip Score (mHHS) were 9.8, 14.4, and 9.14, respectively. Predictive models for achieving the MCID with respect to each were built with the LASSO algorithm (least absolute shrinkage and selection operator) for feature selection, followed by logistic regression on the selected features. Study data were analyzed with PatientIQ, a cloud-based research and analytics platform for health care.

RESULTS

Of 1103 patients who met inclusion criteria, 898 (81.4%) had a minimum of 2-year reported outcomes and were entered into the modeling algorithm. A total of 74.0%, 73.5%, and 79.9% met the HOS-ADL, HOS-SS, and mHHS threshold scores for achieving the MCID. Predictors of not achieving the HOS-ADL MCID included anxiety/depression, symptom duration for >2 years before surgery, higher body mass index, high preoperative HOS-ADL score, and preoperative hip injection (all P < .05). Predictors of not achieving the HOS-SS MCID included anxiety/depression, preoperative symptom duration for >2 years, high preoperative HOS-SS score, and preoperative hip injection, while running at least at the recreational level was a predictor of achieving HOS-SS MCID (all P < .05). Predictors of not achieving the mHHS MCID included history of anxiety or depression, high preoperative mHHS score, and hip injections, while being female was predictive of achieving the MCID (all P < .05).

CONCLUSION

This study identified predictive variables for achieving clinically meaningful outcome after hip arthroscopy for FAIS. Patient factors including anxiety/depression, symptom duration >2 years, preoperative intra-articular injection, and high preoperative outcome scores are most consistently predictive of inability to achieve clinically meaningful outcome. These findings have important implications for shared decision-making algorithms and management of preoperative expectations after hip arthroscopy for FAI.

Arthroscopy for Management of Femoroacetabular Impingement Syndrome in the Military Health System: A 10-Year Epidemiological Overview of Cases with 2-year Follow-up

INTRODUCTION

With the rapid rise in arthroscopy rates for the management of Femoroacetabular Impingement (FAI) Syndrome, it is important to understand current surgical rates and the impact of these surgeries within the Military Health System (MHS). The purpose of this study was to provide an epidemiological descriptive summary of hip arthroscopy for FAI Syndrome in the MHS and describe perioperative healthcare utilization variables.

METHODS

Eligible beneficiaries ages 18-50, undergoing hip arthroscopy with 2-year follow-up after surgery were included. Healthcare utilization data were abstracted from the MHS Data Repository (MDR) from June 2003 to July 2015, and included all visits, costs, procedures, and prescriptions taking place in both military and civilian hospitals worldwide.

RESULTS

1870 patients were included (mean age 32.2 years; 55.5% male). 51.7% of the procedures took place in military versus 48.3% in civilian hospitals. Mean hip-related healthcare costs in the 2-year following surgery were $15,434 per patient. Patients had a median of 3 opioid prescriptions and 72% had a comorbidity present after surgery. Generally, rates of surgery grew annually from 66 cases in 2004 to 422 cases in 2013. Overall complication rates were comparable to other published reports. Procedures in both military and civilian hospitals had the same rates of femoroplasty and labral repairs, however acetabuloplasty procedures occurred at a higher rate in military (18.9%) vs civilian (14.7%) hospitals. Only 58.8% of patients had physical therapy in the year prior to surgery, while 82.7% had it after surgery. Additionally, 50% of patients had received opioid prescriptions in the 1 year prior to surgery, while 38.9% had 3 or greater opioid prescriptions beyond the initial perioperative fill within the 2-year follow-up.

CONCLUSION

Rates of arthroscopy have grown in the MHS over the last decade. Complication rates are similar to those reported in other populations and settings. Utilization of physical therapy was much more likely after surgery than prior to it. Opioid use was high prior to surgery and many individuals continued to receive opioid prescriptions beyond the initial perioperative period.

Return to Duty After Mini-Open Arthroscopic-Assisted Treatment of Femoroacetabular Impingement in an Active Military Population

Purpose

To report the return-to-duty rate and surgical outcomes in a military population after mini-open arthroscopic-assisted surgery for femoroacetabular impingement (FAI) in an effort to affirm its efficacy.

Methods

A retrospective review of consecutive active-duty patients receiving mini-open arthroscopic-assisted surgery for FAI between 2007 and 2011 was performed. Patients younger than 18 years, non–active-duty patients, and patients with prior hip surgery were excluded. Demographic, radiographic, and duty-status data were collected. The primary outcome measure was a return to duty. Outcome scores were obtained in a proportion of the cohort, including the modified Harris Hip Score, Single Assessment Numeric Evaluation score, Western Ontario and McMaster Universities Osteoarthritis Index score, patient satisfaction score, and Veterans RAND 12 (VR-12) score. All patients had achieved a minimum of 1 year of follow-up at the time of assessment. All P values for significance were set at .05 or lower.

Results

Of 182 patients (average age, 30.4 years), 156 (86%) were available for follow-up with return-to-duty data at an average of 2.8 years (range, 1-6 years). Of the patients, 78% returned to full duty (53%) or returned to duty with restrictions (25%). Outcome scores were available for 101 of 182 patients (55%) with duty rates similar to the total cohort (81% who returned to duty: 58% with no restrictions and 23% with restrictions). Return to duty correlated with improved outcomes compared with those who were medically discharged with respect to the modified Harris Hip Score (68.2 vs 54.5, P < .03), Single Assessment Numeric Evaluation score (48.2 vs 25.3, P < .02), and VR-12 physical (39.7 vs 33.2, P < .05) and VR-12 mental (54.5 vs 43.4, P < .005) scores.

Conclusions

Mini-open arthroscopic-assisted surgery for FAI is successful in returning most service members to duty at short-term follow-up. Return correlates with improved outcome scores, although previously reported minimally clinical important difference and patient acceptable symptomatic state threshold values were not uniformly achieved.

Level of Evidence

Level IV, retrospective case series.

The Presence of a Psychiatric Condition is Associated With Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Matched Case-Controlled Study

BACKGROUND

We sought to examine the association between having a psychiatric condition and undergoing hip arthroscopy for femoroacetabular impingement (FAI).

METHODS

A matched case-control study was performed to control for age and gender. All patients over 16 years of age with FAI treated with hip arthroscopy by a single surgeon were randomly matched to a patient of the same age and gender undergoing knee arthroscopy for any diagnosis other than infection by the same surgeon during the same period. Conditional logistic regression was used to compare the odds of having a psychiatric condition between groups.

RESULTS

Fifty-one matched pairs of patients undergoing hip and knee arthroscopy were identified. Each group contained 35 females (69%) and had a mean age of 33.6 years. Of the 51 hip arthroscopy cases, 23 (45.1%) had a psychiatric condition. Of the 51 knee arthroscopy controls, 11 (21.6%) had a psychiatric condition. Patients undergoing hip arthroscopy were statistically significantly more likely to have a psychiatric condition compared to patients undergoing knee arthroscopy with an odds ratio of 3.4 (95% confidence interval 1.3-9.2, P < .01).

CONCLUSION

There was a strong association between having a psychiatric condition and undergoing hip arthroscopy for FAI. More research should be done investigating psychiatric conditions among patients with FAI and whether this association can identify strategies to optimize patient outcomes.

Does the Use of Psychotropic Medication Adversely Affect the Outcomes of Hip Arthroscopy?

BACKGROUND

Over the past decade, the use of psychotropic medications (PTMs) in the United States has doubled, and currently 20% of adults are taking 1 or more of these antidepressant, antianxiety, antipsychotic, or mood-altering medications. To date, however, the incidence of PTM use in patients undergoing hip arthroscopy and the results of hip arthroscopy in these patients have not been reported.

PURPOSE

To determine the prevalence of PTM use in patients undergoing hip arthroscopy and to compare the outcomes of patients taking PTMs versus those of patients not taking PTMs.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Medical records of 880 consecutive patients who underwent hip arthroscopy performed by the senior author were reviewed and data were collected, including the number and types of PTMs that these patients were taking at the time of their hip arthroscopy. All hips were assessed with the Byrd modified Harris Hip Score (mHHS) preoperatively; 709 patients (81%) had scores obtained at 12 months and 669 patients (76%) at 24 months after surgery. Demographic data and mHHS of patients taking psychotropic medications (PTM group) were compared with those of patients not taking PTMs (NPTM group).

RESULTS

Four hundred twenty-two (48%) of the 880 patients studied were taking PTMs at the time of their hip arthroscopy; significant differences between the PTM and NPTM groups were average age (48 vs 35 years, respectively), and the high percentage of females (53%) and low percentage of males (38%) in the PTM group. Preoperative scores for the PTM and NPTM groups were similar (41 vs 42 points, respectively), but postoperative scores of the PTM group were significantly lower at 6 months (72 vs 89 points), 12 months (77 vs 91 points), and 24 months (79 vs 88 points) after surgery ( P = .01). In contrast, the scores of the subgroups of PTM and NPTM adolescents obtained at 3 months (92.5 vs 88.9 points), 6 months (92.1 vs 90.3 points), 12 months (89.5 vs 92.1 points), and 24 months (90.3 vs 90.1 points) after surgery did not significantly differ.

CONCLUSION

The incidence of PTM use in this series of patients with hip arthroscopy was triple that reported for US adults (48% vs 17%, respectively) and adolescents (23% vs 6.3%), and the PTM group had significantly lower 12- and 24-month mHHS results than the NPTM group. These results suggest that (1) patients undergoing hip arthroscopy who are taking PTMs are at significantly higher risk for poor outcomes and (2) their use of PTMs should be identified and addressed before proceeding with hip arthroscopy.

Comorbidities in the first 2 years after arthroscopic hip surgery: substantial increases in mental health disorders, chronic pain, substance abuse and cardiometabolic conditions

Objectives

We aimed to identify the rate of seven comorbidities (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) that occurred within 2 years after hip arthroscopy.

Methods

Data from individuals (ages 18–50 years) undergoing arthroscopic hip surgery between 2004 and 2013 were collected from the Military Health System (MHS) Data Repository (MDR). The MDR captures all healthcare encounters in all settings and locations for individuals within the MHS. Person-level data over 36 months were pulled and aggregated. Seven comorbidities related to poor outcomes from musculoskeletal disorders (mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders) were examined 12 months prior and 24 months after surgery. Changes in frequencies were calculated as were differences in proportions between presurgery and postsurgery.

Results

1870 subjects were identified (mean age 32.24 years; 55.5% men) and analysed. There were statistically significant increases (p<0.001) proportionally for all comorbidities after surgery. Relative to baseline, cases of mental health disorders rose 84%, chronic pain diagnoses increased 166%, substance abuse disorders rose 57%, cardiovascular disorders rose by 71%, metabolic syndrome cases rose 85.9%, systemic arthropathy rose 132% and sleep disorders rose 111%.

Conclusions

Major (potentially ‘hidden’) clinical comorbidities increased substantially after elective arthroscopic hip surgery when compared with preoperative status. These comorbidities appear to have been overlooked in major studies evaluating the benefits and risks of arthroscopic hip surgery.

Level of evidence

Prognostic, level III.

Editorial Commentary: The Warrior Athlete: An Illustrative Microcosm in the War Against Hip Femoroacetabular Impingement

From an orthopaedic perspective, our military personnel truly are warrior athletes. Distilling the information available in these subjects provides an enlightening microcosm of the management of femoroacetabular impingement (FAI). Symptoms associated with damage caused by FAI represent the culmination of a process present since childhood. Thus, while arthroscopic correction can result in significant improvement, it does not invariably result in full restoration of function. Numerous factors influence an individual's response to injury and recovery from surgery, including subjective parameters such as resiliency. Thus, function is not always based simply on objective parameters. In view of compelling literature to support the efficacy of arthroscopic correction and treatment of FAI, servicemen and women have historically been discriminated against by unilateral lack of coverage. This trend has only partly been reversed as it is now deemed acceptable for active-duty personnel but arbitrarily not for their dependent family members. The war on FAI goes on in terms of better understanding of the FAI enemy, better techniques and technology to use during the war, and better solicitation of the homeland resources for continuing this important battle.

Most Military Service Members Return to Activity Duty With Limitations After Surgery for Femoroacetabular Impingement Syndrome: A Systematic Review

PURPOSE

Determine which proportion of active-duty service members return to duty (RTD), RTD without limitations, which surgical intervention returns these personnel at a better proportion and with the ability to perform their military duties after surgery compared with the pre-injury state.

METHODS

A computer-assisted search of MEDLINE, EMBASE and SCOPUS databases was performed with keywords related to RTD for femoroacetabular impingement (FAI) syndrome. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for study methodology. Methodologic quality of individual studies was assessed with the Methodological Index for Non-Randomized Studies scale.

RESULTS

A total of 5 studies (884 service members/886 hips) qualified for inclusion. Limited evidence from level III to IV studies indicates that service members RTD at a proportion ranging from 57% (95% confidence interval [CI]: 53% to 62%) to 84% (95% CI: 73% to 91%), but only 39% (95% CI: 35% to 44%) to 59% (95% CI: 49% to 69%) do so without limitations. Mean duration of follow-up was 33.2 ± 11.3 months. No studies reported on actual duty requirements before versus after surgery, RTD criteria, or career longevity. Only 1 of 5 studies reported the RTD time-frame (mean 5 months). Only 2 of 5 studies reported complications, with a rate of 9.4% ± 6.3%. Three of 5 studies reported failures at a rate of 7.2% ± 4.7%, respectively. Femoroplasty (mean 56% of procedures in 4 studies) and acetabuloplasty (mean 55% of procedures in 4 studies) were the most commonly used procedures in studies reporting.

CONCLUSIONS

RTD is poorly defined in the included studies. Limited evidence substantiates that approximately 75% of service members remain on active duty for at least 1 to 2 years after surgery for FAI syndrome, whereas only approximately 47% do so without limitations at mid-term follow-up. Similarly, despite improvements in patient-reported outcome measures, service members still report continued pain and functional limitations after FAI syndrome surgery.

LEVEL OF EVIDENCE

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

Editorial Commentary: Hip Arthroscopy in a Military Population: Are the Results Comparable to an Athletic Population?

Hip pain is common in the military population and has led to an increase in hip arthroscopy as a means of therapeutic treatment. Return to duty (RTD) is the measure by which military surgeons tend to judge their outcomes; could the servicemember "get back in the fight?" Return to play (RTP) is a common metric in sports medicine for assessing the effectiveness of a surgical intervention. The results of prior studies of RTD hip arthroscopy in the US military population have been underwhelming when compared with RTP in athletic cohorts. This discrepancy in outcomes likely has more to do with the differences in RTD and RTP as outcome measures than any surgeon, pathology, or demographic factors.

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 Arthroscopy for Femoroacetabular Impingement in a Military Population

BACKGROUND

Femoroacetabular impingement (FAI) can lead to hip pain and early joint degeneration. There have been few reports to date on the outcomes of hip arthroscopy for the treatment of FAI in the military population. Purpose/Hypothesis: The purpose of this study was to compare patient demographics with postoperative outcomes after hip arthroscopy for symptomatic FAI and to identify preoperative risk factors for poor outcomes. The hypothesis was that certain preoperative patient characteristics will be predictive of poorer outcomes and that lower outcomes scores will be associated with a higher likelihood of medical separation from the military.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Retrospective chart review of active-duty and dependent patients older than 18 years who underwent hip arthroscopy for symptomatic FAI from 2009 to 2014 at a single institution.

RESULTS

A total of 469 (309 males and 160 females) surgeries were performed on 456 active-duty personnel and 13 dependent civilians, with a mean 2.5-year follow-up. Overall, 39% (n = 179) were able to return to duty (RTD), 18% (n = 82) were medically cleared to return to normal daily activities but did not remain on active duty, and 43% (n = 195) required referral to the Disability Evaluation System (DES). Increasing rank and male sex were positive predictors and Axis 1 psychiatric diagnosis, revision surgery, concomitant psoas tenotomy, multiple medical comorbidities, and complaints of generalized pelvic pain were negative predictors for returning to duty. US Marine Infantry and Special Forces showed improved RTD rates (50%-86%) compared with administrative, more sedentary, occupations (22%). On average, Single Alpha Numeric Evaluation (SANE) and visual analog scale (VAS) scores improved after surgery, with SANE scores improving 37 ± 28 points and VAS scores improving 2.6 ± 2.5 points. The mean postoperative SANE and VAS scores differed significantly between the RTD group and those not returning to duty; 87 and 1.2 points compared with 69 and 3.6 points, respectively ( P < .0001).

CONCLUSION

Hip arthroscopy for the treatment of symptomatic FAI effectively improves pain symptoms and self-reported overall function but shows a much lower than expected return to full, unrestricted active duty in the general active-duty military population. Underlying psychiatric diagnoses, female sex, and more sedentary occupations are associated with lower RTD rates. Furthermore, lower postoperative SANE and VAS scores are associated with lower RTD rates. Only the more active and elite components of the military study population showed RTD rates consistent with previously reported outcomes of return to competitive sports after hip arthroscopy for FAI.

Arthroscopic treatment of posterior shoulder instability in patients with and without glenoid dysplasia: a comparative outcomes analysis

BACKGROUND

The purpose of this study was to evaluate the influence of glenoid dysplasia on outcomes after isolated arthroscopic posterior labral repair in a young military population.

METHODS

Thirty-seven male patients who underwent arthroscopic posterior labral repair for symptomatic posterior shoulder instability were evaluated at a mean duration of 3.1 years. A comparative analysis was performed for those with glenoid dysplasia and without dysplasia. Additional factors analyzed included military occupational specialty (MOS), preoperative mental health clinical encounters and mental health medication use, and radiographic characteristics (version, posterior humeral head subluxation, and posterior capsular area) on a preoperative standard shoulder magnetic resonance arthrogram. The groups were analyzed with regard to shoulder outcome scores (subjective shoulder value [SSV], American Shoulder and Elbow Surgeons [ASES] rating scale, Western Ontario Shoulder Instability Index [WOSI]), need for revision surgery, and medical separation from the military.

RESULTS

Of 37 patients, 3 (8.1%) underwent revision surgery and 6 (16%) underwent medical separation. Overall outcome assessment demonstrated a mean SSV of 67.9 (range, 25-100) ± 22.1, mean ASES of 65.6 (range, 15-100) ±  22, and mean WOSI of 822.6 (range, 5-1854) ± 538. There were no significant differences in clinical outcome scores between the glenoid dysplasia and no dysplasia groups (SSV, P = .55; ASES, P = .57; WOSI, P = .56). MOS (P = .02) and a history of mental health encounters (P = .04) were significantly associated with diminished outcomes.

CONCLUSIONS

The presence or absence of glenoid dysplasia did not influence the outcome after arthroscopic posterior labral repair in a young military population. However, a history of mental health clinical encounters and an infantry MOS were significantly associated with poorer clinical outcomes.

Short-term outcomes of open hip preservation surgery for symptomatic extraarticular femoroacetabular impingement

INTRODUCTION

The purposes of this study were to describe: (i) short-term disease-specific patient-reported outcome scores (PROMs); and (ii) factors associated with reoperation or treatment failure in patients undergoing open hip preservation surgery for symptomatic extraarticular FAI.

METHODS

Patients undergoing open hip preservation surgery for symptomatic extraarticular FAI were identified from a prospective, single-centre hip preservation registry (n = 51 patients; median clinical follow-up 24 [range 11-49] months). Hip-specific PROMs were assessed preoperatively, 6 months, and each year subsequently. Patients undergoing reoperation or treatment failure (<10 point improvement in iHOT-33 postoperatively) over the study period were identified. Preoperative associated factors were explored on a univariate basis.

RESULTS

International Hip Outcome Tool-33 (iHOT-33) improved from 33 (standard deviation [SD] 18) to 62 (26) at most recent follow-up and 76% of patients improved by minimum clinically important difference (MCID). Harris Hip Score improved from 53 (15) to 75 (17) at most recent follow-up and 79% of patients improved by MCID. Hip Outcome Score (HOS) Sport improved from 45 (26) to 66 (28) at most recent follow-up and 60% of patients improved by MCID. Continued improvements in mean follow-up scores were seen from 1 year to 2 years. Overall, 7 patients underwent reoperation and 9 patients failed to improve by MCID. Preoperative HOS Sport was higher in patients experiencing reoperation or treatment failure (58 [SD 19] vs. 40 [SD 27] respectively; p = 0.03). No other associated demographic, physical examination, or radiographic factors were found.

CONCLUSIONS

Open treatment of extraarticular FAI results in short-term improvements in hip-specific PROMs in most patients. Higher HOS Sport scores were associated with reoperation or treatment failure. Longer-term follow-up is necessary to define maximum improvements in this challenging patient population.

Assessment of Disability Related to Femoroacetabular Impingement Syndrome by Use of the Patient-Reported Outcome Measure Information System (PROMIS) and Objective Measures of Physical Performance

BACKGROUND

The National Institutes of Health (NIH)-sponsored Patient-Reported Outcomes Measurement System (PROMIS) has been described as a valuable tool for characterizing outcomes among patients with specific musculoskeletal conditions. Additionally, previously proposed objective measures of physical performance among patients with nonarthritic hip abnormalities are costly and not practically incorporated into routine clinical practice.

PURPOSE

(1) To determine the ability of the PROMIS to differentiate between patients with femoroacetabular impingement (FAI) and asymptomatic controls, (2) to determine the effect of FAI on subjects' completion of timed physical performance measures, and (3) to determine whether associations exist between established patient-reported outcome (PRO) measures and subjects' completion of physical performance measures.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Twenty-two asymptomatic controls (CON group) and 20 patients with FAI completed multiple activities to assess physical ability: self-selected walking velocity (SSWV), timed stair ascent (TSA), four-square step test (FSST), and sit-to-stand five times test (STS5). All subjects also underwent a battery of PRO questionnaires: Visual Analog Scale for Pain (VAS), Modified Harris Hip Score (mHHS), International Hip Outcome Tool (iHOT-33), Hip Disability and Osteoarthritis Outcome Score (HOOS), and PROMIS. Descriptive analyses were performed and comparisons between groups were made by use of paired t tests with Bonferroni-Holm correction. Spearman's rank correlation coefficients were used to determine associations between physical performance measures and PRO. The magnitude of differences between groups for each measured variable was calculated by use of Cohen's d.

RESULTS

Significant differences between CON and FAI groups were observed for all hip-specific PRO measures (CON vs FAI for all; HOOS 99.2 vs 42.8, P < .001, iHOT-33 99.0 vs 26.6, P < .001, mHHS 99.6 vs 62.2, P < .001). Similarly, PROMIS scores were significantly different between groups for 8 of 9 tested domains. Patients with FAI demonstrated significant decrements in performance of all tested physical measures compared with asymptomatic controls (CON vs FAI, SSWV: 1.51 vs 1.32 m/s, P = .002; TSA: 3.05 vs 5.92 s, P = .017; FSST: 4.83 vs 8.89 s, P = .006; STS5: CON 5.53 vs FAI 10.75 s, P = .005.) Deficits in activities involving hip flexion-TSA, STS5-were strongly associated ( r < -0.7, P < .001) with increased reports of disability.

CONCLUSION

FAI has a negative effect on patient-reported and objectively measured function. Hip-specific and general measures such as PROMIS, FSST, TSA, and STS5 are responsive to FAI-associated debility and may be used to objectively assess surgical or rehabilitative outcomes.

Iatrogenic Hip Instability Treated With Periacetabular Osteotomy

Hip dislocation following hip arthroscopy is a devastating complication. Previous reports of arthroscopy-related iatrogenic instability have focused on strategies aimed at restoring the stabilizing effects of the hip joint capsuloligamentous complex. Less has been written about treatment options for patients in whom deficient acetabular coverage of the femoral head is implicated in the functionally unstable hip joint. Given this relative paucity of information, an optimal treatment approach has yet to be elucidated for these patients. Periacetabular osteotomy has been described as a treatment for iatrogenic hip instability related to surgical hip dislocation; however, to our knowledge, this is the first case of a patient with hip arthroscopy-related iatrogenic instability manifesting as recurrent, frank dislocations treated with periacetabular osteotomy.

Return to Function, Complication, and Reoperation Rates Following Primary Pectoralis Major Tendon Repair in Military Service Members

BACKGROUND

Pectoralis major tendon ruptures have become increasingly common injuries among young, active individuals over the past 30 years; however, there is presently a paucity of reported outcome data. We investigated the ability to return to full preoperative level of function, complications, reoperation rates, and risk factors for failure following surgical repair of the pectoralis major tendon in a cohort of young, highly active individuals.

METHODS

All U.S. active-duty military patients undergoing pectoralis major tendon repair between 2008 and 2013 were identified from the Military Health System using the Management Analysis and Reporting Tool (M2). Demographic characteristics, injury characteristics, and trends in preoperative and postoperative self-reported pain scale (0 to 10) and strength were extracted. The ability to return to the full preoperative level of function and rates of rerupture and reoperation were the primary outcome measures. Univariate analysis followed by multivariate analysis identified significant variables.

RESULTS

A total of 257 patients with pectoralis major tendon repair were identified with a mean follow-up (and standard deviation) of 47.8 ± 17 months (range, 24 to 90 months). At the time of the latest follow-up, 242 patients (94%) were able to return to the full preoperative level of military function. Fifteen patients (5.8%) were unable to return to duty because of persistent upper-extremity disability. A total of 15 reruptures occurred in 14 patients (5.4%). Increasing body mass index and active psychiatric conditions were significant predictors of inability to return to function (odds ratio, 1.56 [p = 0.0001] for increasing body mass index; and odds ratio, 6.59 [p = 0.00165] for active psychiatric conditions) and total failure (odds ratio, 1.26 [p = 0.0012] for increasing body mass index; and odds ratio, 2.73 [p = 0.0486] for active psychiatric conditions).

CONCLUSIONS

We demonstrate that 94% of patients were able to return to the full preoperative level of function within active military duty following surgical repair of pectoralis major tendon rupture and 5.4% of patients experienced rerupture after primary repair. Increasing body mass index and active psychiatric diagnoses are significant risk factors for an inability to return to function and postoperative failures.

LEVEL OF EVIDENCE

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

Prevalence of Symptoms of Depression, Anxiety, and Posttraumatic Stress Disorder in Workers With Upper Extremity Complaints

Study Design Cross-sectional cohort study. Background Symptoms of depression, panic disorder (PD), and posttraumatic stress disorder (PTSD) have been associated with musculoskeletal complaints and could represent barriers to recovery in injured workers. Objectives To determine the prevalence of symptoms of depression, PD, and PTSD utilizing the Patient Health Questionnaire (PHQ) in a cohort of patients presenting to an upper extremity injured-worker clinic; secondarily, to identify any relationships between patients screening positive and patient-reported outcome measures. Methods In 2010, 418 patients completed the PHQ during their initial evaluation. Patients with PHQ scores exceeding threshold values for symptoms of depression, PD, or PTSD were compared based on patient-reported outcome scores, including the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) and Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). The prevalence of symptoms, and their relationship with presenting complaints and patient-reported outcomes, were calculated. Results Thirty-one percent of patients scored above thresholds for symptoms of at least 1 mental health disorder. Of those who screened positive, 67% screened positive for depression, 44% for PTSD, and 50% for PD, with 43% of patients positive for multiple symptoms. Patients experiencing neck pain had significantly higher screening rates of depressive symptoms (62.5% versus 20.1%, P = .004) and PD (37.5% versus 12.9%, P = .044) compared with other presenting complaints. Similarly, patients with chronic pain had higher rates of depression (54.5% versus 20.1%, P = .006), PD (63.6% versus 12%, P<.001), and PTSD (36.4% versus 14.8%, P = .05) compared with other presenting complaints. Patients endorsing depressive symptoms had significantly lower SF-36 mental component summary scores (26.3 ± 10.7 versus 37.6 ± 9.9, P<.001) and higher shortened-version DASH (72.3 ± 16.7 versus 61.5 ± 11.1, P = .003) and DASH work scores (86.5 ± 19.2 versus 82.1 ± 20.1, P = .007) compared to patients endorsing other items on the PHQ. Conclusion In this prospective cohort study of injured workers, we identified a relatively high prevalence of symptoms of psychological disorders utilizing the PHQ, with one third of injured workers screening positive for symptoms of depression, PD, or PTSD. Further longitudinal follow-up is necessary to determine the impact on treatment outcomes. Level of Evidence Symptom prevalence, level 1b. J Orthop Sports Phys Ther 2016;46(7):590-595. Epub 12 May 2016. doi:10.2519/jospt.2016.6265.

What the Papers Say

The Journal of Hip Preservation Surgery (JHPS) is not the only place where work in the field of hip preservation may be published. Although our aim is to offer the best of the best, we continue to be fascinated by work that finds it way into journals other than our own. There is much to learn from it so JHPS has selected six recent and topical articles for those who seek a brief summary of what is taking place in our ever-fascinating world of hip preservation. What you see here are the mildly edited abstracts of the original articles, to give them what JHPS hopes is a more readable feel. If you are pushed for time, what follows should take you no more than 10 min to read. So here goes …