Surgical predictability is a multifactorial methodology of coordinated actions backed by clinical expertise and historical tracking. Recent research shows outcome after ipsilateral hip arthroscopy ...predicts outcomes on the contralateral side, regardless of time between surgeries. This is based on research by experienced surgeons who have achieved reproducibility, predictability, and consistency of their outcomes. To patients at time of scheduling, this translates to, "Trust us, we know what we’re doing." This research may not be generalizable to low volume or inexperienced hip arthroscopists.
To assess mid- to long-term patient-reported outcomes (PROs) of hip arthroscopy as well as the rates of secondary surgery and to identify indications for surgery and noted predictors of failure.
A ...systematic review of the current literature was performed with the terms “hip arthroscopy,” “outcomes,” “patient-reported outcomes,” “mid-term,” “5-year,” “long-term,” and “10-year” in the PubMed, Cochrane, and Embase databases in April of 2020 according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Data for study characteristics, patient demographics, follow-up time, indications for surgery, PROs, predictors of failure or unfavorable PROs, and rates of secondary hip preservation surgery and conversion to total hip arthroplasty were collected.
Thirteen articles were included. Four studies were level III and 9 were level IV. In total, 1571 hips were included, and the average follow-up time ranged from 60 to 240 months. The most common indications for hip arthroscopy were labral tears and femoroacetabular impingement syndrome. Twelve studies reported on PROs and all reported improvement at latest follow-up. The most reported on scores were the modified Harris Hip Score, Harris Hip Score, and the Hip Outcome Score-Sport Specific Subscale. When grouped based on average follow-up time, the conversion rates at the 5- and 10-year time points ranged from 3.0% to 17.9% and 2.4% to 32.5%, respectively. One study with 20-year follow-up reported a conversion rate of 41.0%. Osteoarthritis and increased age were the most cited predictors for secondary surgery or decreased PROs.
At mid- to long-term follow-up, patients who underwent primary hip arthroscopy demonstrated improvement in several PROs. There was great variability in rates for revision surgery and conversion to total hip arthroplasty. The most common indications for hip arthroscopy were labral tears and femoroacetabular impingement syndrome. Osteoarthritis and increased age were the most cited predictors for unfavorable outcomes.
Level IV, systematic review of Level III and IV studies.
BACKGROUND:Robotic-assisted technology has been a reliable tool in enhancing precision and accuracy of cup placement in total hip arthroplasty (THA). Still, questions remain on the clinical benefit ...of this technology.
METHODS:The purposes of the ongoing study were (1) to report on minimum 5-year outcomes in patients who underwent robotic-assisted primary THA (rTHA), (2) to compare those outcomes to a propensity score–matched manual primary THA (mTHA) control group, and (3) to compare radiographic measures between the groups regarding acetabular cup placement. Prospectively collected patient data were retrospectively reviewed for primary THA recipients during June 2008 to July 2013. Patients with minimum 5-year follow-up for Harris Hip Score, Forgotten Joint Score-12, Veterans RAND-12 Mental, Veterans RAND-12 Physical, 12-Item Short Form Survey Mental, 12-Item Short Form Survey Physical, visual analog scale, and satisfaction were included. Patient-reported outcomes, cup placement, and revision rate of the rTHA group were compared with those of a propensity score–matched mTHA control group.
RESULTS:Sixty-six rTHAs were matched to 66 mTHAs. The rTHA group reported significantly higher Harris Hip Score, Forgotten Joint Score-12, Veterans RAND-12 Physical, and 12-Item Short Form Survey Physical (P < 0.001, P = 0.002, P = 0.002, P = 0.001). The acetabular implant placement by rTHA had a 9 and 4.7-fold reduced risk of placement outside the Lewinnek and Callanan safe zones, respectively (relative risk, 0.11 95% confidence interval, 0.03 to 0.46; P = 0.002; relative risk, 0.21 95% confidence interval, 0.01 to 0.47; P = 0.001). In addition, rTHA recipients had lesser absolute values of leg length discrepancy and global offset (P = 0.091, P = 0.001).
CONCLUSIONS:Patients who received rTHA reported favorable outcomes at minimum 5-year follow-up. Furthermore, in comparison to a propensity score pair–matched mTHA group, rTHAs reported higher patient-reported outcome scores and had 89% reduced risk of acetabular implant placement beyond the Lewinnek safe zone and 79% reduced risk of placement beyond the Callanan safe zone.
LEVEL OF EVIDENCE:Level III
Background:
Although hip arthroscopy has been shown to have favorable results, there is a paucity of literature describing predictive factors of 5-year clinical outcomes.
Purpose:
To identify ...predictive factors of midterm outcomes after hip arthroscopy in a cohort of 1038 patients whose outcomes at minimum 2-year follow-up were previously reported. In addition, to provide a comparison of short- and midterm predictive factors in outcome measures after hip arthroscopy.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Data were prospectively collected and retrospectively reviewed on all patients undergoing hip arthroscopy between February 2008 and June 2012. Patients were included if they had minimum 5-year follow-up on 2 patient-reported outcomes: Nonarthritic Hip Score (NAHS) and modified Harris Hip Score. Patients were excluded if they had any previous ipsilateral hip conditions. Using bivariate and multivariate analyses, we analyzed the effect of 36 pre- and intraoperative variables on the NAHS, modified Harris Hip Score, and conversion to total hip arthroplasty.
Results:
A total of 1038 patients met the inclusion criteria for the 2-year study, and 860 met our listed inclusion criteria for the 5-year study. The mean follow-up time was 62.0 months (range, 60.0-120.0 months). The bivariate analysis identified 10 variables (4 categorical and 6 continuous) that were predictive of 5-year postoperative NAHS. For the multivariate analysis, 7 variables were identified as being significant: preoperative NAHS, body mass index (BMI), age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. These 7 variables were also predictive in the bivariate analysis. Age, BMI, revision hip arthroscopy, Tönnis grade, sex, trochanteric bursectomy, femoral head cartilage damage, and acetabular inclination were significant predictors of conversion to total hip arthroplasty.
Conclusion:
This study reports favorable midterm clinical outcomes in the largest cohort of hip arthroscopies with minimum 5-year follow-up in the literature to date. Seven variables were identified as being significant predictors of postoperative NAHS in the bivariate and multivariate analyses: preoperative NAHS, BMI, age, lateral joint space, alpha angle, revision hip arthroscopy, and acetabular microfracture. Of these, preoperative NAHS, BMI, age, and revision hip arthroscopy were predictive of 2- and 5-year postoperative NAHS. These predictive factors may prove useful to clinicians in determining indications for hip arthroscopy and counseling patients on its expected outcomes.
To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the visual analog scale ...(VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following hip arthroscopy for femoroacetabular impingement syndrome and labral tear, and to identify preoperative predictors of reaching the mHHS, NAHS, VAS, and the iHOT-12 thresholds for achieving the MOI.
An anchor question was provided to patients who underwent hip arthroscopy between April 2008 and April 2019. Patients were included if they answered the anchor question and had minimum 1-year follow-up. Patients were excluded if they had a previous ipsilateral hip surgery, a Tönnis grade >1, hip dysplasia, or a previous hip condition. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. Multivariate logistic regression was used to determine predictors of achieving the MOI threshold.
In total, 407 hips (375 patients) were included, with 279 female patients (68.6%). The average age, body mass index, and follow-up time were 38.8 ± 13.7 years, 26.6 ± 5.8, and 51.8 ± 33.2 months, respectively. Satisfaction with the current state of their hip was reported in 77.9% (317) of the cases. It was determined that 54.8%, 52.5%, 55.5%, and 55.8% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, VAS, and iHOT-12, respectively. Predictors of achieving MOI were not identified.
Following hip arthroscopy in the context of femoroacetabular impingement syndrome and labral tear, the thresholds for achieving the MOI for the mHHS, NAHS, VAS for pain, and iHOT-12 were 54.8%, 52.5%, 55.5%, and 55.8% respectively. No preoperative predictors of achieving the MOI were identified.
IV, case-series.
(1) To report minimum 2-year patient-reported outcome (PRO) scores of primary circumferential acetabular labral reconstruction using anterior tibialis allograft and the knotless pull-through ...technique in the setting of femoroacetabular impingement syndrome (FAIS) and irreparable labral tears and (2) to compare these PROs with a matched-pair primary labral repair group.
Data were prospectively collected and retrospectively reviewed. Patients were included if they underwent primary circumferential labral reconstruction with anterior tibialis tendon allograft during February 2016 to April 2017 for irreparable labral tears and FAIS and had preoperative and minimum 2-year follow-up for modified Harris Hip Score (mHHS), Hip Outcome Score–Sport-Specific Subscale, Non-arthritic Hip Score, International Hip Outcome Tool 12 (iHOT-12), 12-Item Short Form Health Survey physical component and mental component, Veterans RAND 12-Item Health Survey physical component and mental component, and visual analog scale for pain. The exclusion criteria were previous ipsilateral hip conditions or surgical procedures, Tönnis grade 2 or higher, or dysplasia (lateral center-edge angle ≤ 18°). Labral tears were considered irreparable if the labrum appeared (1) to be mostly or completely calcified and (2) to be inadequate (nonviable) and not amenable for labral repair. The reconstruction group was matched 1:3 based on age, sex, and body mass index to a benchmark control group of hips undergoing labral repair from the same period. The minimal clinically important difference and patient acceptable symptomatic state for the mHHS and iHOT-12 score were calculated.
A total of 37 hips (37 patients) underwent circumferential labral reconstruction. There were 19 female patients (51.4%) and 18 male patients (48.6%). The mean age was 45.6 ± 11.6 years, and the average body mass index was 27.1 ± 5. At minimum 2-year follow-up, the circumferential labral reconstruction group showed statistically significant improvements in the mHHS, Non-arthritic Hip Score, Hip Outcome Score–Sport-Specific Subscale, iHOT-12 score, and visual analog scale score. All hips in the reconstruction group were successfully matched to 111 labral repair hips. At latest follow-up, improvements in all PROs between the 2 groups were comparable. The revision rates were 0% and 3.6% in the reconstruction and repair groups, respectively.
After primary hip arthroscopy, primary circumferential labral reconstruction using anterior tibialis allograft and the knotless pull-through technique in the setting of FAIS and irreparable labral tears resulted in significant improvements in several PROs at minimum 2-year follow-up and high patient satisfaction. Primary circumferential labral reconstruction reached comparable functional outcomes to those of a benchmark matched-pair primary labral repair control group.
Level III, case-control study.
The use of traction during hip arthroscopy is commonly used to provide safe joint access and to improve visualization. However, traction during hip arthroscopy has been associated with complications ...ranging from transient neuropraxias to devastating soft-tissue necrosis. Trendelenburg positioning may be helpful, but the degree to which this is true is not well understood.
To determine whether there would be a reduction in perineal pressure at 5°, 10°, and 15° of Trendelenburg compared with baseline (0° of Trendelenburg) while in the modified supine position during hip arthroscopy.
A consecutive cohort of 50 patients treated with hip arthroscopy by a single, high-volume orthopaedic surgeon was analyzed. There were 30 females and 20 males in this study, with a mean age of 36 ± 16 years (range, 14 to 66 years); mean BMI was 26 kg/m. In the operating room, patients were placed in the modified supine position on a traction extension table with a well-padded perineal post. A standard blood pressure cuff was secured to the post to measure pressure exerted on the perineum as traction was applied to distract the hip. For each patient, pressure against the perineum was measured at four different positions using a digital level: 0°, 5°, 10°, and 15° of Trendelenburg. These positions were tested in a random order for each patient. Mean pressure was compared within patients under the four-period crossover design using a repeated-measure (mixed) ANOVA model. Examination of the residual error quantile plot showed that the pressure data followed a normal distribution, making the use of a parametric model appropriate. Tests were made for period and order effects.
Compared with baseline (0° or no Trendelenburg) there was a reduction in pressure of 4.4 (15.5%) at 5° of Trendelenburg (p = 0.203), 8 (28%) at 10° of Trendelenburg (p = 0.022) and 13.1 (46%) at 15° (p = 0.006). These results were maintained regardless of the sequence of positions used in each patient (0°, 5°, 10°, 15°).
Trendelenburg positioning of 10° and 15° during hip arthroscopy resulted in decreased perineal pressure compared with the neutral (0°) position. This technique is intended to harness gravity to exert the majority of countertraction while retaining the perineal post as a backup patient stabilizer. Routine introduction of Trendelenburg during hip arthroscopy reduces perineal pressure against the post, which may decrease complications related to traction and perineal pressure. Future studies should assess whether the observed differences in perineal pressure will reduce the frequency of post-related complications after hip arthroscopy.
Level II, therapeutic study.
Background:
Hip arthroscopy for the treatment of instability in the setting of borderline dysplasia is controversial. Capsular management in such cases is an important consideration, and plication ...has been described as a reliable technique, with good midterm outcomes reported when indications are appropriate.
Hypothesis:
Patients with borderline dysplasia who have a lower lateral center-edge angle (LCEA) and greater age will be at a higher risk of failure after arthroscopic capsular plication.
Study Design:
Case-control study; Level of evidence, 3.
Methods:
Data were retrospectively reviewed for all patients between 15 and 40 years of age who underwent hip arthroscopy from November 2008 to January 2015. Inclusion criteria were an LCEA between 18° and 25°, Tönnis grade ≤1, primary case with capsular plication, and minimum 2-year follow-up. Patients were excluded if they had any history of ipsilateral hip procedure or conditions such as Legg-Calve-Perthes disease, slipped capital femoral epiphysis, rheumatologic disease, and Tönnis grade ≥2. Age, sex, and body mass index data were retrieved for each patient. Patient-reported outcomes (PROs)—including modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Sports Specific Subscale, and a visual analog scale (VAS) for pain (0-10)—were obtained preoperatively and at a minimum of 2 years postoperatively, in addition to the postoperative International Hip Outcome Tool–12. The “success” group consisted of all patients who achieved the patient acceptable symptomatic state of mHHS ≥74 and had no ipsilateral hip surgery subsequent to their index arthroscopy. The “failure” group was composed of patients who were below the patient acceptable symptomatic state at latest follow-up or required secondary arthroscopy or conversion to total hip arthroplasty. Patient satisfaction and minimal clinically important difference were also calculated. Mean age for the failure group was applied as a cutoff age for subanalysis, and relative risk for failure was determined.
Results:
Ninety patients (97 hips; 79.5%) met criteria for the success group, and 25 patients (25 hips) met criteria for the failure group. No significant differences in preoperative baseline scores or VAS were found. However, there did appear to be a trend that the failure group had lower mean preoperative scores for all PRO measures and a higher VAS score. The differences in preoperative mHHS and NAHS closely approached significance (P = .053). Postoperative PRO, VAS, and patient satisfaction scores of the success group were significantly higher than the failure group. The failure group was significantly older than the success group (28.5 ± 7.8 vs 23.5 ± 7.5 years, P = .005). Patients >35 years old were 2.25 times more likely to fail according to relative risk (95% CI, 1.10-4.60; P = .0266). LCEA did not differ between the groups, and no other risk factors for failure were identified.
Conclusion:
Stringent criteria for patient selection and meticulous repair or augmentation of the static stabilizers of the hip yielded favorable clinical outcomes in this study cohort with borderline dysplasia. Within this carefully selected group, the analysis revealed that increased age was the main risk factor for failure in the management of borderline hip dysplasia via isolated primary arthroscopic hip surgery with capsular plication.
Abstract Most surgeons rely on the greater trochanter as the reference point to establish the anterolateral portal. Nevertheless, we believe that the anterosuperior iliac spine is a more reliable ...landmark. Unlike the greater trochanter, it is unaffected by leg rotation and is more easily identified by palpation. Abiding by the central tenet of medicine to “do no harm,” the technique described herein presents in detail the concept of the 12 o’clock portal placement, a hip joint access method based on identifying specific anatomic points under fluoroscopy and by palpation. To accomplish this goal, this Technical Note presents a step-by-step approach, including tips and pearls for patient positioning and fluoroscopic guidance. We believe this method ensures a reproducible and safe way to start hip arthroscopy in the supine position.
(1) To identify present indications for secondary procedures in patients with failed hip arthroscopy and (2) to assess patient-reported outcomes (PROs) of the secondary procedures, including revision ...arthroscopy, periacetabular osteotomy (PAO), and total hip arthroplasty (THA).
Study groups included patients who had a secondary procedure after failed previous hip arthroscopy whereas the control groups were patients who had a primary procedure but did not require a secondary procedure. Indications and procedures at the time of the secondary operation were documented for each study. Average PROs were recorded, and standardized mean difference was calculated to estimate effect size.
Eighteen studies reporting on patients undergoing a secondary procedure after a previous hip arthroscopy were included. The 3 main secondary procedure groups were revision hip arthroscopy, secondary PAO, and secondary THA. Regarding the revision arthroscopy group, the most common indications were labral tears, cam deformity, and pincer deformity. In addition, the most common procedures were femoroplasty, acetabuloplasty, capsular release, and labral reconstruction. The most common indications for the secondary PAO and THA groups were dysplasia and osteoarthritis respectively. Five of the revision arthroscopy studies found that revision patients had worse outcomes than the primary arthroscopy group. One PAO study found that the previous arthroscopy group had slightly worse outcomes, and 2 studies found no differences in PROs. Two THA studies reported worse outcomes for the prior arthroscopy group, and 2 studies reported no differences in outcomes.
The most common indications for revision hip arthroscopy were labral tears and femoroacetabular impingement. Patients undergoing a revision hip arthroscopy demonstrated good postoperative outcomes but to an overall lesser extent than their primary counterparts. The secondary PAO and THA groups also had favorable PROs, but the studies were inconclusive in determining superior outcomes between the primary and secondary groups.
IV, Systematic review of Level II-IV investigations.
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