Original Article
Primary Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes and Clinical Benefit Achievement Rates at Short-Term Follow-Up: A Multicenter Analysis

https://doi.org/10.1016/j.arthro.2022.11.020Get rights and content

Purpose

To report minimum 2-year follow-up patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS). Second, to determine risk factors for revision surgery.

Methods

Prospectively collected data from two high-volume hip arthroscopy centers were retrospectively reviewed on adolescents (≤19 years old) who underwent primary hip arthroscopy between November 2008 and February 2019. Adolescents with a minimum 2-year follow-up for the modified Harris Hip Score (mHHS), Non-Arthritic Hip Score (NAHS), Hip Outcome Score-Sports Specific Subscale (HOS-SSS), International Hip Outcome Tool-12 (iHOT-12), and visual analog scale (VAS) for pain were included regardless of their growth plate status. Exclusion criteria were Tönnis grade >1, lateral center edge-angle <18°, and previous ipsilateral hip surgery or conditions. Preoperative and postoperative radiographic data, MCID, PASS, MOI, secondary surgeries, and complications were reported. A multivariable survival analysis for risk factors for secondary surgery was conducted.

Results

A total of 287 hips (249 patients) were included (74.9% females). The mean values for age, body mass index, and follow-up were 16.3 ± 1.3 years, 22.3 ± 3.5, and 26.6 ± 9.4 months, respectively. Further, 88.9% underwent labral repair, 81.5% femoroplasty, and 85.4% capsular closure. Improvement for all PROs was reported (P < .001) with high patient satisfaction (8.8 ± 1.5). Achievement for the MCID was 71.7%, 83.0%, 68.1%, and 79.5% for the mHHS, NAHS, HOS-SSS, and iHOT-12, respectively. Achievement for the PASS was 68.3% for the mHHS and 73.2% for the NAHS. The MOI for mHHS, NAHS, and VAS was 58.3%, 77.0%, and 59.6%, respectively. Rates of revision hip arthroscopy, cam recurrence, and heterotopic ossification were 5.8%, 1.7%, and 5.5%, respectively. Acetabular retroversion was found to be a risk factor for revision surgery (P = .03).

Conclusion

The results of this multi-center study demonstrated that adolescents who underwent primary hip arthroscopy for FAIS reported significant improvement in all PROs, with satisfactory achievement rates for the MCID, PASS, MOI, and high patient satisfaction at a minimum 2-year follow-up.

Level of Evidence

IV, retrospective multicenter study.

Introduction

Femoroacetabular impingement syndrome (FAIS) is a frequent cause of hip pain in adolescent patients.1,2 Management of FAIS in the adolescent population includes both nonoperative and operative alternatives. Treatment of adolescents entails unique challenges,3 often with high demands on and expectations for their hips in combination to an also high baseline functional statuses.4 with depression, anxiety, and suicidal behavior among youths being a worldwide major public health concern.5 Depression and anxiety are predictors for worse functional status at baseline and postoperative in hip arthroscopy patients.6,7

Physical therapy has shown to be an effective first-line treatment. Pennock et al. reported that 82% of adolescent patients presenting with FAIS experienced significant improvement with a nonsurgical protocol—rest, physical therapy, and activity modification—at 2 years.8 Zogby et al. demonstrated that adolescents treated nonoperatively for FAIS reported significant improvement for the modified Harris Hip Score (mHHS) and the Non-arthritic Hip Score (NAHS) at the 1- and 2-year marks, and outcomes did not deteriorate at the 5-year mark.9 Nonetheless, a subset of patients will progress to require surgical intervention.10

Similar to the adult population,11 the incidence of hip arthroscopy has been increasing in the adolescent population, with Hassan et al. reporting a 6.2-fold increase between 2008 and 2018.12 Migliorini et al. systematically reviewed 406 adolescents (470 hips) who underwent hip arthroscopy, reporting excellent outcomes, with significant improvement in hip pain, function, and quality of life, with a revision rate of 5% at a mean follow-up of 30.4 months.13 Hip arthroscopy for the management of FAIS has led to satisfactory outcomes from short-term to mid- and long-term follow-up, as reported by Nwachukwu et al.,14 Beck et al.,15 and Fukase et al.,16 respectively. Nevertheless, most analyses of hip arthroscopy on adolescents are from a single institution with modest sample sizes.2,15,17,18

The purpose of the present multicenter study was to report minimum 2-year follow-up, patient-reported outcome scores (PROs) and rates of achieving the minimal clinically important difference (MCID), the patient-acceptable symptomatic state (PASS), and the maximal outcome improvement (MOI) on adolescents following primary hip arthroscopy for FAIS. Secondly, to determine risk factors for revision surgery. It was hypothesized that adolescents who underwent primary hip arthroscopy, in the setting of FAIS and labral tear, would experience improvement in all PROs, high patient satisfaction, and high achievement rates for the MCID, PASS, and MOI at a minimum 2-year follow-up.

Section snippets

Methods

This study was performed at the American Hip Institute Research Foundation, performed in accordance with the ethical standards in the 1964 Declaration of Helsinki and carried out in accordance with relevant regulations of the U.S. Health Insurance Portability and Accountability Act (HIPAA). Details that might disclose the identity of the subjects under study have been omitted. This study was approved by the Institutional Review Board. (IRB ID: 5276).

Results

After combining both data registries, a total of 287 hips (249 patients) with minimum 2-year follow-up were included (92.9% follow-up) (Fig 1). All baseline demographic characteristics are shown in Table 1. The mean age was 16.3 ± 1.3 years, mean body mass index (BMI) was 22.3 ± 3.5, and mean follow-up time was 26.9 ± 9.4 months. Preoperative and postoperative LCEA, Tönnis angle, ACEA, and alpha angle are shown in Table 2.

Discussion

The main finding of the present multicenter study was that there was significant improvement in all collected PROs for included adolescents undergoing primary hip arthroscopy for the treatment of FAIS. Moreover, satisfactory achievement rates for the MCID, PASS, MOI, and patient satisfaction were reported.39 Furthermore, the presence of acetabular retroversion was identified as a risk factor for revision surgery.

In a systematic review by Chen et al.,40 data were analyzed from 10 studies,

Limitations

The limitations of this study must be acknowledged. Short-term follow-up results were reported; therefore, longer follow-up is necessary to determine the durability of the results. Albeit data were prospectively collected, the study was retrospective in design, which introduced bias. Additionally, the intraoperative decision making-algorithm and surgical techniques may differ among the involved surgeons. The analysis was based on high-volume centers that specialize in hip arthroscopic surgery,

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    See commentary on page 1220

    The authors report the following potential conflicts of interest or sources of funding: A.J.K. reports grants from Aesculap/B. Braun, DJO LLC, personal fees from Arthrex, and Responsive Arthroscopy LLC, outside the submitted work. He also reports board membership/committee member with American Journal of Sports Medicine, International Cartilage Repair Society, International Society of Arthroscopy, Knee Surgery, and Orthopaedic Sports Medicine. Full ICMJE author disclosure forms are available for this article online, as supplementary material. B.G.D. is a board member of the American Hip Institute Research Foundation, AANA Learning Center Committee, the Journal of Hip Preservation Surgery, and the Journal of Arthroscopy; he has ownership interests in the American Hip Institute, Hinsdale Orthopedic Institute, Hinsdale Orthopedic Imaging, SCD#3, North Shore Surgical Suites, and Munster Specialty Surgical Center. He also reports grants from the American Orthopedic Foundation (during the conduct of the study), Medacta, Stryker, Breg, Medwest Associates, ATI Physical Therapy, and Ossur, during the conduct of the study; personal fees from Amplitude, DJO Global, Stryker, Orthomerica, and St. Alexius Medical Center. He also have received patents 8708941, Adjustable multi-component hip orthosis with royalties paid to Orthomerica and DJO Global; 8920497, Method and instrumentation for acetabular labrum reconstruction with royalties paid to Arthrex; and 9737292, Knotless suture anchors and methods of tissue repair with royalties paid to Arthrex. B.A.L. reports personal fees from Arthrex and Smith & Nephew and stock or stock options from COVR Medical, outside the submitted work. He also reports editorial board membership of Journal of Knee Surgery, Knee Surgery, Sports Traumatology, Arthroscopy, and Orthopedics Today. D.R.M. reports nonfinancial support from Arthrex, Stryker, Ossur, and Smith & Nephew, outside the submitted work. He is also an editorial board member of the Journal of Arthroscopy. K.R.O. reports personal fees from Arthrex, Smith & Nephew, Endo Pharmaceuticals, and Pinnacle, outside the submitted work.

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