Parth Lodhia

Patient-Reported Outcome Instruments for Femoroacetabular Impingement and Hip Labral Pathology: A Systematic Review of the Clinimetric Evidence

PURPOSE The purpose of this study is to systematically review the content and clinimetric evidence (rigor of rating scales and indexes for the description of clinical phenomena) of published patient-reported outcome (PRO) instruments used to assess femoroacetabular impingement (FAI) and labral hip pathology. METHODS We used Medical Subject Heading terms related to FAI and labrum/labral tears to search the Medline, Embase, and Cochrane databases for studies of FAI and labral hip pathology. Studies with hip-related PRO instruments, with any operative intervention except total hip arthroplasty, were included. We excluded studies with a skeletally immature population, revision surgeries in more than 10% of cases, or a primary diagnosis of hip osteoarthritis. We conducted a second review using the same databases for studies reporting clinimetric properties of at least 1 of the PRO instruments identified previously. Articles were selected in an independent, stepwise manner by 2 reviewers. Selected articles were evaluated to determine the presence and quality of measurement properties of the outcome instruments. RESULTS We found 5 articles assessing 3 PRO instruments: the Hip Outcome Score (HOS), the Non-Arthritic Hip Score, and the 12-item modified Western Ontario and McMaster Universities Osteoarthritis Index. The HOS had the highest positive rating for internal consistency, construct validity, agreement, responsiveness, lack of floor/ceiling effect, and interpretability. The Non-Arthritic Hip Score showed evidence for validity and lack of floor/ceiling effect. The modified Western Ontario and McMaster Universities Osteoarthritis Index was only strong for internal consistency and was indeterminate for construct validity. CONCLUSIONS Only 3 PRO instruments have shown clinimetric evidence to support their use to measure outcomes in FAI and labral pathology patients. The HOS has the greatest amount of clinimetric evidence and is the most proven instrument for use in this population. This review shows that further clinimetric evaluation of commonly used PRO instruments for nonarthritic hip pathology is warranted.

How Much Arthritis Is Too Much for Hip Arthroscopy: A Systematic Review

PURPOSE The purpose of this study was to determine the extent of preoperative osteoarthritis (OA) that precludes benefit from hip arthroscopy by systematically reviewing the literature on hip arthroscopy in the setting of OA. METHODS We searched the Medline and PubMed databases using the following Medical Subject Heading terms: arthritis, osteoarthritis, chondral damage, chondral injury, chondral delamination, and hip arthroscopy. Two authors independently reviewed the literature and included articles if they were in the English language; commented on preoperative factors, parameters, physical examination, or diagnostic testing that may be evidence of cartilage damage and/or arthritis; contained outcome data on patients undergoing hip arthroscopy; and had a sample size of at least 10 patients with arthritic changes in the hip. We excluded review articles, technique articles, articles with overlapping patient populations, articles with hip arthroscopy used as an adjunct to an open procedure, articles with inflammatory and septic arthritis, and articles with a mean age younger than 18 years. RESULTS Our search identified 518 articles, of which 15 met the inclusion and exclusion criteria. Two thousand fifty-one hips underwent arthroscopy at a mean patient age of 40.2 years. Of these, 1,195 hips had signs of OA. There were 345 conversions to total hip arthroplasty/surface replacement arthroplasty. Of these patients, 274 had OA. Eight patient-reported outcome instruments were used. Factors influencing outcomes were preoperative OA, age, chondral damage, femoroacetabular impingement, and duration of symptoms. CONCLUSIONS Current evidence is insufficient to define a cutoff for how much arthritis is too much for hip arthroscopy. However, this analysis shows that patients with a Tönnis grade of 1 or greater or a joint space of 2 mm or less are less likely to benefit from hip arthroscopy and more likely to require conversion to total hip arthroplasty/surface replacement arthroplasty. Postoperative scores on patient-reported outcome instruments are lower in the arthritic population at follow-up compared with their nonarthritic counterparts. LEVEL OF EVIDENCE Level IV, systematic review of Level III and IV studies.

Arthroscopic Technique of Capsular Plication for the Treatment of Hip Instability

Atraumatic instability or microinstability of the hip is a recognized cause of groin pain and hip instability. Risk factors include female sex, ligamentous laxity, and borderline dysplasia. Arthroscopically, the joint may distract easily, and there may be associated ligamentum teres tears and laxity of the capsule on manual probing. The use of arthroscopic capsular plication in this cohort of patients has shown good to excellent results. Biomechanically, a capsular plication aims to create an imbrication and inferior shift of the capsule to augment the screw-home mechanism of the capsuloligamentous structures and thereby improve stability in extension and external rotation. The purpose of this article is to detail the step-by-step surgical technique of arthroscopic capsular plication, in addition to the indications, pearls, and pitfalls of the technique.

Outcomes of Hip Arthroscopy in Patients with Tönnis Grade-2 Osteoarthritis at a Mean 2-year Follow-up: Evaluation Using a Matched-pair Analysis with Tönnis Grade-0 and Grade-1 Cohorts

BACKGROUND Osteoarthritis adversely impacts hip arthroscopy outcomes. The purpose of this study was to conduct a matched-pair analysis with a mean follow-up of 2 years to evaluate the outcomes following hip arthroscopy in patients with Tönnis grade-2 osteoarthritis. METHODS Data were prospectively collected on all patients undergoing hip arthroscopy during the study period from April 2008 to December 2012. Patients were excluded if they had previous hip conditions. Patients were categorized into Tönnis grade-0, grade-1, or grade-2 osteoarthritis groups and were matched in a 1:1 ratio according to age within 5 years, sex, and body mass index. Four patient-reported outcome scores, a visual analog scale (VAS) score for pain, patient satisfaction level, and rates of revision hip arthroscopy and conversion to total hip arthroplasty were recorded. RESULTS During the study period, 1,412 hip arthroscopies were performed. Of those, 1,079 satisfied the inclusion criteria, and 935 (86.7%) of them had a follow-up of 2 years. Seven hundred and thirty-eight, 154, and 43 patients had Tönnis grade-0, grade-1, and grade-2 osteoarthritis, respectively. Thirty-seven patients were matched in each group. All groups demonstrated a significant improvement in patient-reported outcomes and VAS scores. A good-to-excellent result was seen in 69.7%, 75.8%, and 65.4% of the patients in the Tönnis grade-0, grade-1, and grade-2 groups, respectively. No significant difference among the groups was found with respect to the mean change in patient-reported outcomes, VAS scores, and patient satisfaction level. There was no significant difference in the rate of revision arthroscopy. Tönnis grade-2 hips had an odds ratio for conversion to total hip arthroplasty of 7.73 (95% confidence interval [CI], 2.00 to 29.83) compared with Tönnis grade-0 hips and 4.36 (95% CI, 1.38 to 13.4) compared with Tönnis grade-1 hips. CONCLUSIONS Hips with Tönnis grade-2 osteoarthritis had a significantly higher rate of conversion to total hip arthroplasty at the 2-year follow-up compared with matched cohorts of Tönnis grade-0 and grade-1 hips. Thus, hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Microfracture in the Hip Results of a Matched-Cohort Controlled Study With 2-Year Follow-up

Background: Microfracture in hip preservation surgery has demonstrated favorable outcomes, but studies with a higher level of evidence assessing microfracture are warranted. Purpose: To assess 2-year outcomes of patients who underwent hip arthroscopy with full-thickness chondral damage treated with microfracture and compare these outcomes with those of a control group from a similar cohort of patients who did not have full-thickness chondral damage and who were not treated with microfracture. Study Design: Cohort study; Level of evidence, 3. Methods: Between February 2008 and May 2012, prospectively gathered data for patients undergoing microfracture during hip arthroscopy with a 2-year follow-up were reviewed. All patients were assessed pre- and postoperatively at 3 months, 1 year, and 2 years with 4 patient-reported outcome (PRO) instruments. A matched cohort of patients who did not have full-thickness chondral damage and hence did not receive microfracture was selected on a 1:2 ratio. Matching criteria were sex, age within 6 years, workers’ compensation status, concomitant labral treatment, and radiographic parameters. Statistical analyses were performed to compare the change in PROs in both groups. Results: A total of 79 hips were included in the microfracture group and 158 in the control group. There was no significant difference in PRO scores preoperatively between the groups. Both groups demonstrated significant improvement in all postoperative PRO scores at all time points. There was no statistically significant difference in postoperative PRO scores between the microfracture and control groups, except for the visual analog scale (VAS) score at 2 years, which was higher (P = .02) in the microfracture group (mean ± SD, 3.63 ± 2.50) than in the control group (2.82 ± 2.76). Patient satisfaction was 7.2 for the microfracture group and 8.04 for the control group, which was statistically different (P < .05). The mean change in all PRO scores was similar between groups at 3 months and 1 year postoperatively but significantly lower in the microfracture group at 2 years postoperatively. The greatest improvement in both groups was noted at 3 months postoperatively. Conclusion: This study showed that patients undergoing microfracture during hip arthroscopy had equivalent PRO scores compared with the control group at 2 years postoperatively. The change in PRO scores from preoperatively to 2 years postoperatively was significantly lower in the microfracture group compared with the control group. The VAS scores and satisfaction were inferior by 0.81 and 0.84 units, respectively, in the microfracture group compared with the control group, likely due to lack of full-thickness chondral defects in the latter. However, both groups showed significant improvement in all PRO scores after surgery, with no significant difference in final PRO scores.

Outcomes of Open Versus Endoscopic Repair of Abductor Muscle Tears of the Hip: A Systematic Review

PURPOSE To compare the outcome of open versus endoscopic gluteal tendon repair. METHODS An extensive review of PubMed was conducted by 2 independent reviewers for articles containing at least 1 of the following search terms: gluteus medius, gluteus medius tear, gluteus medius tendinopathy, gluteus medius repair, hip abductors, hip abductor tears, hip abductor repair, hip rotator cuff, hip rotator cuff repair, trochanteric bursa, trochanteric bursitis, trochanteric bursectomy, peritrochanteric procedures, peritrochanteric repair, and peritrochanteric arthroscopy. This yielded 313 articles. Of these articles, 7 satisfied the following inclusion criteria: description of an open or endoscopic gluteal repair with outcomes consisting of patient-reported outcome scores, patient satisfaction, strength scores, pain scores, and complications. RESULTS Three studies on open gluteal repairs and 4 on endoscopic gluteal repairs met the inclusion criteria. In total, there were 127 patients who underwent open procedures and 40 patients who underwent endoscopic procedures. Of the 40 patients who underwent endoscopic procedures, 15 had concomitant intra-articular procedures documented, as compared with 0 in the open group. The modified Harris Hip Score was common to 1 study on open repairs and 3 studies on endoscopic repairs. The scores were similar for follow-up periods of 1 and 2 years. Visual analog pain scale scores were reported in 1 study on open gluteal repairs and 1 study on endoscopic repairs and were similar between the 2 studies. Improvement in abductor strength was also similarly reported in selected studies between the 2 groups. The only difference between the 2 groups was the reported incidence of complications, which was higher in the open group. CONCLUSIONS Open and endoscopic gluteal repairs have similar patient-reported outcome scores, pain scores, and improvement in abduction strength. Open techniques have a higher reported complication rate. Randomized studies of sufficient numbers of patients are required to ultimately determine if one technique produces superior patient outcomes over the other. LEVEL OF EVIDENCE Level IV, systematic review of Level IV studies.

Outcomes of Endoscopic Gluteus Medius Repair: Study of Thirty-four Patients with Minimum Two-Year Follow-up.

BACKGROUND Surgical intervention for partial and full-thickness gluteus medius tears is often recommended for patients who have persistent pain despite nonoperative treatment. Traditionally, the surgical intervention has been carried out through open techniques with good results; however, advantages of endoscopic techniques include less tissue dissection, improved tendon mobilization, and the benefit of arthroscopic correction of intra-articular pathological conditions. The purpose of this report is to provide an update on a previously published study of patients with a gluteus medius tear, with inclusion of additional patients followed for a minimum of two years. METHODS The study included thirty-four patients who had undergone an endoscopic gluteus medius repair with correction of intra-articular pathological conditions between April 2009 and April 2012 and had been followed for a minimum of two years. Patient-reported outcome measures included the modified Harris hip score, Nonarthritic Hip Score, and Hip Outcome Score-Activities of Daily Living and Sport-Specific Subscale. A visual analog scale (VAS) pain score and a patient satisfaction score were also recorded. RESULTS The cohort consisted of two men and thirty-two women with a mean age of fifty-seven years (range, twenty to seventy-nine years). Ten patients had a full-thickness tear, and twenty-four patients had a partial-thickness tear. Seventeen patients were treated with a suture bridge technique, after completion of the tear if it was not already complete, and seventeen patients were treated with the transtendinous technique. All patients had surgical correction of intra-articular pathological conditions. There was a significant improvement in all four patient-reported outcomes at three specified time-points. The mean VAS pain score decreased from 6.6 preoperatively to 2.4 at the time of the two-year follow-up (p < 0.001). The mean satisfaction score was 8.5 at two years postoperatively. Of twenty-six patients who had a gait deviation preoperatively, fifteen (58%) regained a completely normal gait. There was no significant difference in patient-reported outcome measures between the two surgical techniques. Four patients required total hip replacement at eleven to sixteen months postoperatively. CONCLUSIONS After a minimum of two years of follow-up, endoscopic surgical repair with correction of intra-articular pathological conditions was found to be an effective treatment for patients with a gluteus medius tear.

Microfracture in the hip: a matched-control study with average 3-year follow-up

There is a paucity of literature regarding microfracture surgery in the hip. The purpose of this study was to compare outcomes in patients undergoing hip arthroscopy predominantly for labral tears with focal full thickness chondral damage on the acetabulum or femoral head treated with microfracture and a matched control group that did not have focal full thickness chondral damage. A prospective matched-control study was performed examining four patient-reported outcome (PRO) scores: modified Harris Hip Score (mHHS), non-arthritic hip score, Hip Outcome Score—Activities of Daily Living (HOS-ADL), and Hip Outcome Score—Sports Specific Subscale (HOS-SSS) at minimum 2 years post-operatively between 35 patients undergoing microfracture for chondral defects during hip arthroscopy and 70 patients in a control group that did not have chondral defects. The patients were matched based on gender, age within 7 years, Workman’s compensation claim, labral treatment and acetabular crossover percentage less than or greater than 20. There was no significant difference (P > 0.05) in PRO scores preoperatively between the groups. Both groups demonstrated significant improvement (P < 0.05) in all post-operative PRO scores at all time points. There was no statistically significant difference (P > 0.05) in post-operative PRO scores between the microfracture and control groups, except for HOS-ADL and the visual analog scale (VAS) score, both of which were superior in the control group (P < 0.05). Patient satisfaction was 6.9 for the microfracture group and 7.7 for the control group (P > 0.05). Arthroscopic microfracture of the hip during treatment of labral tears results in favorable outcomes that are similar to the results arthroscopic treatment of labral tears in patients without full thickness chondral damage.

Preoperative Delayed Gadolinium-Enhanced Magnetic Resonance Imaging of Cartilage (dGEMRIC) for Patients Undergoing Hip Arthroscopy: Indices Are Predictive of Magnitude of Improvement in Two-Year Patient-Reported Outcomes.

BACKGROUND Delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) has been used in the detection of chondropathy. Our study aimed to determine whether dGEMRIC indices are predictive of two-year patient-reported outcomes and pain scores following hip arthroscopy. METHODS Between August 2008 and April 2012, sixty-five patients (seventy-four hips) underwent primary hip arthroscopy with preoperative dGEMRIC and a minimum of two years of follow-up. Exclusion criteria were previous hip surgery, slipped capital femoral epiphysis, inflammatory arthropathy, Legg-Calvé-Perthes disease, and arthritis of >1 Tönnis grade. Patients were classified in two groups on the basis of a dGEMRIC cutoff of 323 msec, which was one standard deviation (SD) below the study cohort mean dGEMRIC index of 426 msec. Patient-reported outcome tools used included the modified Harris hip score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score Activities of Daily Living (HOS-ADL), and the Hip Outcome Score Sport-Specific Subscale (HOS-SSS) as well as a visual analog scale (VAS) for pain and a patient satisfaction score. RESULTS There were sixty-four hips that met the inclusion criteria; fifty-two (81.3%) had a minimum of two years of follow-up. Twelve of the sixty-four hips had a dGEMRIC index of <323 msec (Group 1), and fifty-two hips had a dGEMRIC index of ≥323 msec (Group 2). There was no significant difference between the groups with respect to age, sex, and body mass index. There was no significant difference between the groups in mean preoperative patient-reported outcome scores and the VAS for pain. At the two-year follow-up, Group 1 had significant improvement in the mHHS, whereas Group 2 demonstrated significant improvement in all patient-reported outcome scores and the VAS. The improvement in all patient-reported outcome scores was significantly larger for Group 2 compared with Group 1. There was no significant difference in patient satisfaction between groups and no significant correlation between dGEMRIC indices and the patient-reported outcome measures. CONCLUSIONS Patients with a dGEMRIC index of ≥323 msec (less than one SD below the cohort mean) demonstrated significantly greater improvement in patient-reported outcome scores and the VAS for pain after hip arthroscopy.

Clinical Outcomes of Hip Arthroscopic Surgery: A Prospective Survival Analysis of Primary and Revision Surgeries in a Large Mixed Cohort

Background: With the rapid increase in hip preservation procedures, revision hip arthroscopic surgery and conversion to total hip arthroplasty (THA) or hip resurfacing (HR) after primary hip arthroscopic surgery have become a large focus in the recent literature. Purpose: The primary purpose was to perform a survival analysis in a large mixed cohort of patients undergoing hip arthroscopic surgery at a high-volume tertiary referral center for hip preservation with a minimum 2-year follow-up. The secondary purpose was to compare clinical outcomes of primary versus revision hip arthroscopic surgery. Study Design: Cohort study; Level of evidence, 2. Methods: From February 2008 to June 2012, data were prospectively collected on all patients undergoing primary or revision hip arthroscopic surgery. Patients were assessed preoperatively and postoperatively with the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score–Activities of Daily Living (HOS-ADL), and Hip Outcome Score–Sport-Specific Subscale (HOS-SSS). Pain was estimated on a visual analog scale (VAS). Patient satisfaction was measured with the question “How satisfied are you with your surgery results?” (1 = not at all, 10 = the best it could be). Results: There were a total of 1155 arthroscopic procedures performed, including 1040 primary arthroscopic procedures (926 patients) and 115 revision arthroscopic procedures (106 patients). Of these, 931 primary arthroscopic procedures (89.5%) in 824 patients (89.0%) and 107 revision arthroscopic procedures (93.0%) in 97 patients (91.5%) were available for follow-up and included in our study. The mean change in patient-reported outcome (PRO) scores at 2-year follow-up in the primary arthroscopic surgery group was 17.4 for the mHHS, 19.7 for the HOS-ADL, 23.8 for the HOS-SSS, 21.3 for the NAHS, and −3.0 for the VAS, and the mean change in the revision arthroscopic surgery group was 13.4, 10.9, 16.1, 15.4, and −2.7, respectively. All scores improved significantly compared with preoperatively (P < .001). PRO scores were higher at all time points for the primary group compared with the revision group (P < .05). Mean satisfaction was 7.7 and 7.2 for the primary and revision groups, respectively. Of 931 primary arthroscopic procedures, 52 (5.6%) converted to THA/HR. Of 107 revision arthroscopic procedures, 12 (11.2%) converted to THA/HR. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures. The cumulative incidence of competing risks of conversion to THA/HR and revision hip arthroscopic surgery after primary hip arthroscopic surgery was 2.6% and 5.8%, respectively. The overall complication rate was 4.3%. Conclusion: Patients showed significant improvement in all PRO, VAS, and satisfaction scores at 2 years after hip arthroscopic surgery. Patients who underwent primary arthroscopic surgery showed higher PRO scores and a trend toward greater improvement in the VAS score compared with patients who underwent revision arthroscopic surgery. The relative risk of THA/HR was 2.0 after revision procedures compared with primary procedures.