Patients Underwent Revision Hip Arthroscopy Research Articles

Patients Undergoing Revision Hip Arthroscopy With Labral Reconstruction or Labral Repair and Patient-Reported Outcomes: A Systematic Review.

Compromise of the acetabular labrum can lead to pain and loss of critical intra-articular fluid pressure. Revision labral preservation poses unique challenges due to adhesions and compromised tissue quality. The purpose of the study was to evaluate patient-reported outcome (PRO) measures (PROMs) in patients undergoing revision hip arthroscopy with either labral reconstruction or labral repair after primary hip arthroscopy for labral tear. It was hypothesized that both procedures would lead to improved PROs. Systematic review; Level of evidence, 4. A systematic review of the literature was conducted with the following keywords: (revision) AND (hip OR femoroacetabular impingement) AND (arthroscop*) AND (reconstruction OR repair) in PubMed, Cochrane, and Scopus in August 2023 using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria, yielding 2002 initial records. Only studies comparing PROMs between revision labral reconstruction or revision labral repair after primary hip arthroscopy for labral tear were included. Background article information was recorded, including article title, author, study design, level of evidence, patient demographics, radiographic information, intraoperative data, PROMs, psychometric thresholds, and secondary surgeries. Secondary surgery in our study was defined as any open or arthroscopic hip surgery secondary to the initial revision surgery. Forest plots were created for pre- and postoperative outcomes present in ≥3 studies. Heterogeneity was calculated using I 2 values. Four studies, including 215 revision labral reconstructions and 115 revision labral repairs of the hips, were included in this systematic review. All studies were level 3 evidence, and study periods ranged between 2009 and 2019. Mean follow-up for the reconstruction and repair groups ranged from 26.3 to 36.6 months and 30.7 to 56.4 months, respectively. The mean age for the reconstruction and repair groups varied between 27 to 34.6 years and 27.5 to 30 years, respectively. Mean postoperative modified Harris Hip Scores for the reconstruction and repair cohorts ranged from 72.0 to 81.2 and 70.8 to 84.1, respectively (I 2 = 0%). Mean visual analog scale for pain scores for the reconstruction and repair cohorts ranged from 3 to 3.5 and 2.3 to 3.9 (I 2 = 33%). Overall secondary surgery rates ranged from 10.0% to 26.7% in the labral reconstruction cohort, compared with 10.0% to 50.0% in the labral repair cohort. One study reported superior outcomes in the revision labral repair group, with 3 studies finding no statistically significant difference in outcomes between the groups. Our systematic review showed that patients undergoing revision hip arthroscopy with labral reconstruction demonstrated significant improvement in postoperative outcome measures. Postoperative outcomes were similar to those of a benchmark control group of patients undergoing revision hip arthroscopy and labral repair. Labral reconstruction in the revision setting appears to be an effective treatment in clinically indicated patients.

Poster 205: Long-Term Outcomes for Patients Undergoing Revision Hip Arthroscopy

Objectives: Previous studies have reported outcomes after revision hip arthroscopy at mid-term follow-up. These studies demonstrate that patients can expect clinical improvement and low rates of reoperation following their revision surgery. However, in comparison to primary hip arthroscopy patients they experience worse outcomes. The purpose of this study was (1) To evaluate long-term outcomes after revision hip arthroscopy and (2) to identify factors that contribute to poorer outcomes. Methods: Patients who underwent revision hip arthroscopy for FAIS between 1/2012-9/2015 were reviewed. Patients were excluded if they underwent revision hip arthroscopy for a reason other than FAIS, underwent staged or prior PAO, had Tönnis grade > 1, had a history of congenital hip disorder (e.g., slipped capital femoral epiphysis), or were missing 8+ year follow-up. Patient-reported outcome (PRO) measures were collected both pre- and post-operatively including Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sports Scale (HOS-SS), modified Harris Hip Score (mHHS), and international Hip Outcome Tool (iHOT-12). Minimal clinically important difference (MCID) and patient acceptable symptom state (PASS) thresholds were calculated using the distribution and anchor methods, respectively. Rates of MCID and PASS achievement were then evaluated. Rates of reoperation including repeat revision hip arthroscopy and conversion to total hip arthroplasty (THA) were evaluated. Patients were also divided into clinical successes and failures and compared. A clinical failure was defined as failure to achieve MCID or PASS for any PRO or undergoing a reoperation. Results: A total of 43 patients (72% female; age: 30.1 ± 10.3 years; BMI: 25.8 ± 6.0 kg/m2) met criteria for inclusion. Average follow-up was 9.3 years. At last follow-up there were significant improvements across all PROs (p < 0.001, for all). MCID achievement at final follow-up for each PRO was ≥ 56.5%, with achievement of MCID in any PRO occurring in 73.9% of patients. PASS achievement at final follow-up for each PRO was ≥ 29.6%, with achievement of PASS in any PRO occurring in 63.0% of patients. PASS achievement was 75.7% at two years and 75.8% at five years. Incidence of secondary revision hip arthroscopy was 23.3% and THA was 14.0%, occurring at mean 3.9 ± 2.8 years and 4.2 ± 3.0 years following index revision, respectively. 22 patients were considered clinical successes, and 21 patients were determined to be clinical failures. Both groups demonstrated similar age (28.6 ± 8.5 years vs 31.6 ± 11.9, p = 0.351), sex (77.3% female vs 66.7% female, p = 0.438), and BMI (25.7 ± 7.9 vs 25.9 ± 3.6, p = 0.915). Additionally, clinical successes and failures had similar preoperative PROs (p ≥ 0.133, for all). Presence of preoperative pain for over two years occurred more frequently in clinical failures (45.5% vs 76.2%, p = 0.039). Tönnis grade 1 was also present at a higher rate amongst clinical failures (0% vs 23.8%, p = 0.015). Conclusions: Patients undergoing revision hip arthroscopy can see significant clinical improvement, particularly within the first five years following surgery. However, some patients may see clinical decline beyond eight years post-operatively. Revision hip arthroscopy is associated with relatively high reoperation rate. Those with greater Tönnis grade on preoperative radiographs and increased prevalence of chronic preoperative pain were less likely to achieve a clinical success.

Defining the Percent Thresholds for Achieving the Maximum Outcome Improvement of the Modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score-Sports Subscale, the Visual Analog Scale for Pain, and the International Hip Outcome Tool-12 in Revision Hip Arthroscopy at Minimum 2-Year Follow-Up

To determine the respective percent thresholds for achieving the maximal outcome improvement (MOI) for the modified Harris Hip Score (mHHS), the Non-Arthritic Hip Score (NAHS), the Hip Outcome Score-Sports Subscale (HOS-SSS), the visual analog scale (VAS) for pain, and the International Hip Outcome Tool-12 (iHOT-12) that were associated with satisfaction following revision hip arthroscopy, and to identify predictors for achieving the MOI. An anchor question was provided to patients who underwent revision hip arthroscopy between April 2017 and July 2020. Patients were included for the final analysis if they answered the anchor question and had minimum 2-year follow-up. Receiver operating characteristic analysis was used to determine the thresholds for the percentage of the MOI predictive of satisfaction. A P-value of < .05 was considered significant. In total, 318 patients underwent revision hip arthroscopy. Of those patients, 292 (91.8%) had minimum 2-year follow-up. Of this cohort, 68 answered the anchor question, with 49 (72.1%) female and 19 (27.9%) male patients. The mean age, and body mass index time were 32.9 ± 13 years and 25.4 ± 5.1, respectively. It was determined that 42.1%, 50%, 48.1%, 50%, and 50% of MOI were the thresholds for maximal predictability of satisfaction for mHHS, NAHS, HOS-SS, VAS for pain, and the iHOT-12, respectively. The presence of unaddressed subspine impingement was a significant predictor for achieving the MOI threshold for the VAS (odds ratio 1.40; 95% confidence interval 1.00-1.95; P= 0.0273). Following revision hip arthroscopy, the percent thresholds for achieving the MOI at a minimum 2-year follow-up for the mHHS, NAHS, HOS-SS, VAS for pain, and iHOT-12 were 42.1%, 50%, 48.1%, 50%, and 50.9%, respectively. Addressing residual subspine impingement was identified as significant positive predictor for achieving the MOI. Level IV, case-series.

Patients Undergoing Revision Hip Arthroscopy Demonstrate Comparable Survivability and Improvement but Worse Postoperative Outcomes Compared to Patients Undergoing Primary Hip Arthroscopy: A Propensity Matched Study at Five-Year Follow-Up

To compare mid-term clinical outcomes between patients undergoing primary hip arthroscopy (HA) versus revision hip arthroscopy (RHA) for femoroacetabular impingement syndrome (FAIS). A retrospective cohort study was conducted on 1,862 patients who underwent hip arthroscopy for FAIS from January 2012 to April 2017. Patients who underwent RHA were propensity matched in a 1:4 ratio by age, sex, body mass index (BMI), and exercise status to patients who underwent primary HA. Preoperative and postoperative radiographs were assessed. Patient-reported outcomes before and at 5 years after surgery, including the Hip Outcome Score Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS), modified Harris Hip Score (mHHS), international Hip Outcome Tool (iHOT-12), and Visual Analog Scale (VAS) for Pain and Satisfaction, were compared between groups. Minimally clinically important difference and patient-acceptable symptomatic state (PASS) achievement rates were compared using previously published thresholds. Fifty-one patients who underwent RHA (35 female, 16 male; age 36.2 ± 10.2 years; BMI 26.5 ± 5.9) were followed up for 63.9 ± 9.2 months and then propensity matched in a 1:4 ratio by sex, age, and BMI to 204 control patients who underwent primary HA. At midterm follow-up, patients in the RHA cohort had significantly lower scores for HOS-SS (RHA 64.9 ± 32.5 vs HA 75.3 ± 26.2, P= .044), mHHS (RHA 72.2 ± 22.4 vs HA 80.1 ± 18.1, P= .039), and iHOT-12 (RHA 61.4 ± 29.3 vs HA 71 ± 27.6, P= .043) compared to primary HA patients. Rates of achieving PASS were significantly decreased for HOS-SS (RHA 38.3% vs HA 55.4%, P= .039) and iHOT-12 (RHA 41.9% vs HA 59.9%, P= .035) in the RHA cohort. There were no significant differences in rates of conversion to THA or subsequent reoperation on the index hip between groups. Patients undergoing revision hip arthroscopy demonstrate comparable survivability and magnitude of improvement but may experience worse overall outcome scores and meet thresholds for clinically significant outcomes less often when compared to primary hip arthroscopy patients. Level III; retrospective comparative study.

Poster 193: Increased Hip Distractability in the Revision Hip Arthroscopy Setting: A Comparison Between Revision and Native Contralateral Hips with an Intra-Operative Axial Stress Exam Under Anesthesia

Objectives:Hip instability secondary to capsular insufficiency is a cause of persistent pain and/or functional disability following primary hip arthroscopy in a poorly defined subset of patients. Further, an easily distractible hip exam under anesthesia is a finding that has been described in the diagnosis of hip instability; however, the exam has relied on subjective findings of a perceived looseness and has lacked objective criteria. The purpose of this study was to compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation.Methods:Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria was any contralateral hip surgery. Prior to instrumentation, fluoroscopic images of both hips were obtained at 25 lb traction intervals up to 100 lbs. Total joint space and distraction were measured at each traction interval. (Figure 1) Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. (Figure 2) Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips.Results:Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of non-operative hips at traction intervals of 50 lbs (2.13 vs. 1.04 mm, p = 0.002), 75 lbs (6.39 vs. 3.70 mm, p < 0.001), and 100 lbs (8.24 vs. 5.39, p < 0.001) (Figure 3). Mean total joint space of operative hips was significantly greater than mean total joint space of non-operative hips at traction intervals of 50 lbs (6.60 vs. 5.39 mm, p < 0.001), 75 lbs (10.86 vs. 8.05 mm, p < 0.001), and 100 lbs (12.73 vs. 9.73, p < 0.001). A higher percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval (Table 1).Conclusions:In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared to the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability, and can be assessed on a stress exam under anesthesia.Table 1. Total and percentage of hips achieving millimetric distraction thresholds in 2mm intervals up to 10mm in operative and native hips.

Propensity-Matched Patients Undergoing Revision Hip Arthroscopy Older Than the Age of 40 Years Had Greater Risk of Conversion to Total Hip Arthroplasty Compared With Their Primary Counterparts

To report patient-reported outcomes (PROs) and survivorship following revision hip arthroscopy in patients aged ≥40 years and to compare these results with a propensity-matched primary hip arthroscopy control group. Data were prospectively collected and retrospectively reviewed for all patients who underwent revision hip arthroscopy between June 2008 and January 2019. Patients were included if they were ≥40 years of age at the time of surgery and had minimum 2-year follow-up for the modified Harris Hip Score, Nonarthritic Hip Score, Visual Analog Scale for pain, and the Hip Outcome Score-Sports Specific Subscale. Patients who had a previous hip condition, or those who lacked minimum 2-year follow-up, were excluded. The revision group was further analyzed by conducting a 1:1 propensity-matched sub-analysis to a primary hip arthroscopy control group based on age, sex, body mass index, and acetabular labrum articular disruption grade. Statistical significance was set at P < .05. Eighty-nine hips (92.7% follow-up) were included, with 66.3% being females. The mean age, body mass index, and follow-up time were 49.4 ± 8.0 years, 26.6 ± 4.1, and 62.7 ± 38.5 months, respectively. Significant improvement in all PROs (P < .001) was reported, and 71.8%, 58 74.4%, and 65.2% achieved the minimal clinically important difference for the modified Harris Hip Score, Nonarthritic Hip Score, and Hip Outcome Score-Sports Specific Subscale, respectively. Eighty-seven revision hips were successfully propensity-matched to 87 primary hips. Both groups reported similar improvement for all PROs, but the relative risk of conversion to total hip arthroplasty was 2.63 times greater (95% confidence interval 1.20-5.79) for the revision group. Patients aged ≥40 years who underwent revision hip arthroscopy reported significant improvement in all PROs at a mean follow-up of 62.7 months with favorable rates of achieving the minimal clinically important difference. When compared to the propensity-matched control group, both achieved similar rates of improvement, but the revision group was 2.63 times more likely to convert to total hip arthroplasty. III. case-control study.

Magnetic Resonance Arthrogram Improves Visualization of Hip Capsular Defects in Patients Undergoing Previous Hip Arthroscopy

PurposeTo compare magnetic resonance imaging (MRI) with magnetic resonance arthrogram (MRA) in the identification of hip capsular defects in patients who previously underwent hip arthroscopy.MethodsPatients who underwent revision hip arthroscopy for capsular insufficiency by a single surgeon between March 2014 and December 2019 were identified by Current Procedural Terminology code. Patients with arthroscopically confirmed capsular defects treated surgically who underwent both MRI and MRA between their primary and revision surgeries were identified. Imaging studies were blinded, randomized, and distributed to two fellowship-trained musculoskeletal radiologists. Radiologists evaluated 14 components of different anatomic structures, including the presence of capsular defect and defect grading, over 2 months, with a 2-week washout period between 4 sets of reads to obtain 2 complete reads from each radiologist. Data were analyzed in R version 4.0.2.ResultsTwo hundred thirty patients underwent revision hip arthroscopy between March 2014 and December 2019. Twelve patients had both an MRI and an MRA of the operated hip performed between their primary and revision surgeries. Time between primary and revision hip arthroscopy was 2.0 ± 1.5 years (R: .3-6.3). Time between MRI and MRA was .6 ± .6 years (R: .0-1.6). Sensitivity for detecting hip capsular defects was significantly higher for MRA than for MRI (87.5%, 95% CI: [68,96] vs 50%, 95% CI: [31,69], respectively; P = .008).ConclusionsThis retrospective review demonstrates that MRA has higher sensitivity than MRI in detecting surgically confirmed capsular defects. MRA may be more helpful in identifying capsular defects in patients presenting with hip instability symptoms who have had a previous hip arthroscopy.Level of EvidenceLevel IV, diagnostic case series.

Favorable Outcomes of Revision Hip Arthroscopy Irrespective of Whether Index Surgery was Performed by the Same Surgeon or a Different Surgeon.

Introduction:The purpose of this study was to compare minimum 2-year patient-reported outcomes (PROMs) after revision hip arthroscopy between two different patient cohorts who had undergone primary hip arthroscopy with the same surgeon (SS) and a different surgeon (DS). We hypothesized no difference in clinical outcomes between the groups despite differences in intraoperative findings based on the surgical decision making in a revision setting at a high-volume center.Methods:Between January 2012 and August 2017, 71 SS patients were matched for age, sex, body mass index, and follow-up to 71 DS patients. Modified Harris hip score (mHHS), nonarthritic hip score, and hip outcome score—sports-specific subscale (HOS-SSS) were collected prospectively. The minimal clinically important difference was calculated for mHHS and HOS-SSS.Results:All the DS patients had labral tears, and 94.4% had femoroacetabular impingement from residual bony deformity (P < 0.001). The SS and DS groups demonstrated significant and comparable improvement in mHHS (Δ = 18.3 ± 21.5 versus 19 ± 20.1; P = 0.837), nonarthritic hip score (Δ = 18.8 ± 18.8 versus 18.2 ± 18.8; P = 0.850), and HOS-SSS (Δ = 22 ± 27.4 versus 17.5 ± 28.1; P = 0.275). The rates of achieving minimal clinically important difference for mHHS and HOS-SSS were similar. Furthermore, the need for revision surgery and conversion to total hip arthroplasty were comparable (P = 0.228 and P = 0.383).Conclusions:Patients undergoing revision hip arthroscopy reported notable and comparable improvement in multiple patient-reported outcomes at a minimum 2-year follow-up, irrespective of intraoperative findings or primary source of patient pool.

Previous Arthroscopic Hip Surgery Increases Axial Distractibility Compared to the Native Contralateral Hip and May Suggest Instability

To compare intraoperative hip joint distractibility between hips that previously underwent arthroscopic surgery and the contralateral hip with no history of surgical manipulation. Patients undergoing revision hip arthroscopy between April 2019 and December 2020, who previously underwent arthroscopic hip surgery for femoroacetabular impingement syndrome, were prospectively enrolled. Exclusion criteria were any contralateral hip surgery. Before instrumentation, fluoroscopic images of both hips were obtained at 25 lbs traction intervals up to 100 lbs. Total joint space was measured at each traction interval. Distraction was calculated as the difference between the baseline joint space and the total joint space at each subsequent traction interval. Wilcoxon signed ranks tests and McNemar tests were used to compare distraction between revision and native contralateral hips. Forty-seven patients were included. Mean distraction of operative hips was significantly greater than mean distraction of nonoperative hips at traction intervals of 50 lbs (2.13 vs 1.04 mm, P= .002), 75 lbs (6.39 vs 3.70 mm, P < .001), and 100 lbs (8.24 vs 5.39, P < .001). Mean total joint space of operative hips was significantly greater than mean total joint space of nonoperative hips at traction intervals of 50 lbs (6.60 vs 5.39 mm, P < .001), 75 lbs (10.86 vs 8.05 mm, P < .001), and 100 lbs (12.73 vs 9.73, P < .001). A greater percentage of operative hips achieved all distraction thresholds, in 2-mm intervals up to 10-mm, at each traction interval. In the majority of patients undergoing revision hip arthroscopy, previous arthroscopic hip surgery increases axial distractibility of the hip joint compared with the native contralateral hip at axial traction forces of 50-100 lbs. Increased axial distractibility following hip arthroscopy may be suggestive of hip instability and can be assessed on a stress examination with the patient under anesthesia. III, case-control study.

Multicenter Outcomes After Revision Hip Arthroscopy: Comparative Analysis of 2-Year Outcomes After Labral Repair Versus Labral Reconstruction

Background: There is a paucity of literature evaluating patient outcomes in patients undergoing revision labral repair and labral reconstruction. Purpose: To compare outcomes in patients undergoing revision hip arthroscopy for treatment of labral tears by labral repair or labral reconstruction. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective review of a prospectively maintained multicenter database of patients undergoing hip arthroscopy was performed. An a priori power analysis determined that a total of 62 patients were required. Patients undergoing revision hip arthroscopy for labral tears with completed 2-year outcome scores were included. Patients undergoing primary hip arthroscopy, labral debridement, concomitant gluteal repair, and patients with hip dysplasia (lateral center-edge angle <20°) were excluded. Patients were grouped into revision labral repair and labral reconstruction groups. Patient demographics and patient-reported outcomes (PROs) including Hip Outcome Score – Activities of Daily Living, Hip Outcome Score – Sport Subscale, modified Harris Hip Score, international Hip Outcome Tool-12, visual analog scale for pain and satisfaction, and achievement of minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) were analyzed. Results: A total of 40 patients underwent revision labral repair and 55 patients underwent labral reconstruction. Patients undergoing revision labral repair were younger (mean age, 30.0 ± 10.7 years vs 34.4 ± 9.7 years; P = .048), had lower rates of labral degeneration (25.0% vs 62.7%; P = .004), and had lower rates of severe complexity of tears (21.1% vs 66.0%; P = .003). However, the labral repair group had higher rates of articular cartilage damage (62.5% vs 33.3%; P = .009). There were no differences in any preoperative or 2-year postoperative PROs. Furthermore, no differences were seen in achievement of MCID or PASS in any PRO. Conclusion: In this multicenter study on revision hip arthroscopy, patients undergoing revision labral repair were younger and had better labral characteristics but greater cartilage damage compared with patients undergoing labral reconstructions. Despite these differences, patients who underwent labral repair reported similar outcomes to those undergoing labral reconstruction.

Repeat Revision Hip Arthroscopy Outcomes Match That of Initial Revision But Not That of Primary Surgery for Femoroacetabular Impingement Syndrome

To (1) report on pre- and postoperative patient-reported outcome (PRO) scores for patients undergoing repeat revision surgery in short-term follow-up and (2) compare minimal clinically important difference (MCID) and patient acceptable symptomatic state achievement between primary, revision, and repeat revision hip arthroscopy cohorts. Data from consecutive patients undergoing revision hip arthroscopy from January 2012 to February 2019 were retrospectively reviewed. Hips that underwent 2 revision hip arthroscopic surgeries were identified and matched 1:3 to patients undergoing revision surgery and 1:3 to patients undergoing primary surgery by age, sex, and body mass index. Baseline demographic data, surgical indications, and hip-specific PROs were collected were obtained preoperatively and at minimum 1-year follow-up. MCID was calculated individually for each cohort. Twenty patients who underwent repeat revision were matched to 60 patients who underwent revision and 60 primary patients. Patients who underwent repeat revision achieved MCID on all investigated PROs at a similar rate to patients undergoing primary surgery (90.0% vs 91.7%, P= .588) and at a greater rate than patients undergoing first-time revision surgery (90.0% vs 71.7%, P= .045). Patients who underwent repeat revision achieved patient acceptable symptomatic state on all investigated PROs at a similar rate to patients who underwent first-time revision (30.0% vs 55.0%, P= .053) but at a significantly lower rate than primary patients (30.0% vs 76.7%, P < .001). However, patients undergoing repeat revision surgery had significantly lower preoperative PROs (P < .001 for all) and no significant difference in PROs at minimum 1-year follow-up compared with patients undergoing revision (P > .05). Compared with the primary cohort, patients who underwent repeat revision had significantly lower Hip Outcome Score-Activities of Daily Living (77.3 ± 16.7 vs 86.1 ± 14.4; P= .034), Hip Outcome Score-Sports Subscale (60.6 ± 27.2 vs 76.1 ± 23.8; P < .001), and modified Harris Hip Score (69.2 ± 19.3 vs 81.7 ± 16.1; P= .048) at a minimum of 1-year follow-up. Second-time revision hip arthroscopy, which often requires advanced procedures, results in clinically significant improvement in PROs; however, outcomes for repeat revision cases are similar to first-time revision cases but inferior to those obtained following primary surgeries. Level III, retrospective case-control study.

Clinical Outcomes of Hip Arthroscopy in Patients With Systemic Inflammatory Diseases Compared With Matched Controls at a Minimum of 2-Year Follow-Up

To evaluate postoperative outcomes and preoperative risk factors for patients with underlying systemic inflammatory disorders after hip arthroscopy. A retrospective analysis of patients who had undergone hip arthroscopy, with a history of systemic inflammatory disease, was performed. This included patients with a diagnosis of lupus, a positive antinuclear antibody test, rheumatoid arthritis, psoriatic arthritis, sarcoidosis, inflammatory bowel disease, Reiter syndrome, and mixed connective tissue disease. These cases were 1:2 matched to a control group of patients with no history of systemic inflammatory disease based on age and sex. An a priori power analysis was conducted and A 1:2 case-control ratio was selected to increase study power. Inclusion criteria included all skeletally mature patients with hip pain refractory to nonoperative management who underwent hip arthroscopy for labral tears and femoroacetabular impingement. Skeletally immature patients, those with Tönnis grades of 2 or more (less than 2 mm of joint space), hip dysplasia, patients undergoing revision hip arthroscopy, and patients whose pain failed to improve after intra-articular injection were excluded. The primary outcome was rate of revision hip arthroscopy or total hip arthroplasty 24 months after surgery. Secondary outcomes included 2 patient-reported outcome scores, the modified Harris Hip Score (mHHS) and Non-Arthritic Hip Score (NAHS). Twenty patients (21 hip arthroscopy procedures) and 42 controls were included. There was no significant difference in proportion of patients who met failure criteria (28.6% vs 16.7%, P=.271) or 2-year survivorship (76.2% vs 83.3%, P= .496) between the systemic inflammatory disorder and control groups, respectively. Both groups had a significant improvement in mHHS and NAHS at 24 months compared with baseline; however, there was no significant difference in mHHS (P= .28) or NAHS (P= .22) at 24 months between the 2 groups. Patients with underlying inflammatory conditions have similar 2-year outcomes after hip arthroscopy for intra-articular pathology compared with patients with no history of inflammatory disease. III, retrospective comparative study.

Identifying the Most Successful Procedures in Hip Arthroscopy.

Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty. From February 2008 to November 2015, patients undergoing hip arthroscopy for a labral tear with minimum 2-year follow-up and between 18 and 60 years old were retrospectively reviewed. Those with previous surgeries, Tönnis grade greater than 1, and previous hip conditions were excluded. Follow-up was obtained for 1118 patients (1249 hips; 81.7%) with a mean age of 38.7 years (range, 18.0-60.0 years), mean body mass index of 26.4 kg/m2 (range, 16.3-48.9 kg/m2), and mean follow-up of 50.2 months (range, 24.0-111.9 months). A total of 122 (9.8%) patients converted to total hip arthroplasty (mean, 35.3 months; range, 1.4-95.2 months). Multivariate analysis for predictors of total hip arthroplasty found age at surgery (hazard ratio, 1.064/y; P<.05), body mass index (nonlinear; P<.05), labral debridement (HR, 1.558; P=.03), and notchplasty (HR, 2.128; P<.05), with trochanteric bursectomy (HR, 0.367; P<.05) identified as associated with higher survivorship. A total of 124 (9.9%) patients underwent revision hip arthroscopy at a mean of 21.7 months (range, 0.10-83.3 months). Multivariate analysis for predictors of revision surgery found workers' compensation (HR, 3.352; P<.05), capsular repair (HR, 1.950; P<.05), and femoral head microfracture (HR, 2.844; P=.04) to be significant, with age at date of surgery (HR, 0.973/y; P<.05) and femoral head chondroplasty (HR, 0.241; P=.05) associated with higher survivorship. Understanding risk factors for conversion to total hip arthroplasty or revision is paramount during discussions with patients. [Orthopedics. 2020;43(3):173-181.].

Two-Year Patient-Reported Outcomes for Patients Undergoing Revision Hip Arthroscopy with Capsular Incompetency

To determine clinical outcomes of patients undergoing revision hip arthroscopy for failure to improve with magnetic resonance imaging (MRI) and intraoperative evidence of a capsular incompetency as compared with (1) patients undergoing revision hip arthroscopy without evidence of a capsular incompetency and (2) patients undergoing primary surgery for femoroacetabular impingement syndrome (FAIS) at a minimum follow up of 2 years. Data from consecutive patients undergoing revision hip arthroscopy with MRI/arthrogram-confirmed capsular incompetency between January 2012 and June 2016 were analyzed. All revision patients with capsular incompetency was matched 1:1 by age and body mass index to FAIS revision patients without capsular incompetency and primary FAIS patients. Outcomes included the Hip Outcome Score (HOS)-Activities of Daily Living (ADL), HOS-Sports Subscale (SS), Modified Harris Hip Score (mHHS), pain, and satisfaction. The minimal clinically important difference was calculated for HOS-ADL, HOS-SS, and mHHS. In total, 49 patients (54.4%) of 90 undergoing revision hip arthroscopy had MRI evidence of a capsular incompetency. Most patients were female (79.6%), with a mean age of 30 ± 10.5 years and body mass index of 25.7 ± 5.5. The difference among pre- and postoperative HOS-ADL, HOS-SS, mHHS, and visual analog scale score for pain were all statistically significant (P < .05). Analysis of reported outcomes among matched groups demonstrated statistically significant differences, with the group undergoing primary surgery having the greatest 2-year outcomes. Only 66.7% of patients undergoing revision surgery with capsular incompetency achieved a minimal clinically important difference; however, there was no significant difference when compared with revision patients without capsular incompetency. When compared with patients undergoing primary surgery, the difference in frequency was statistically significant (66.7% vs 91.3%; P < .001). More than one half of patients undergoing revision hip arthroscopy had MRI and intraoperative evidence of capsular incompetency. Revision arthroscopy for capsular incompetency results in significantly improved 2-year outcomes. However, patients undergoing revision for capsular incompetency and intact capsule revisionpatients reported significantly lower outcomes compared with primary patients. Level III, Retrospective Comparative Study.

Functional and Clinical Outcomes of Patients Undergoing Revision Hip Arthroscopy With Borderline Hip Dysplasia at 2-Year Follow-up

To compare outcomes of borderline hip dysplasia (BHD) patients undergoing revision hip arthroscopy with 1) patients with BHD undergoing primary hip arthroscopy for femoroacetabular impingement syndrome (FAIS) and 2) patients without BHD undergoing revision hip arthroscopy for FAIS. A retrospective cohort study was performed to identify patients who underwent arthroscopy from January 2012 to January 2016 by a single fellowship-trained surgeon, including a 2-year follow-up. Patient demographics, comorbid medical conditions, and preoperative outcome scores were compared between patients with BHD (lateral center-edge angle 18° to 25°) who had revision hip arthroscopy to patients with BHD undergoing primary arthroscopy and patients without BHD (lateral center-edge angle >25°) undergoing revision arthroscopy. Cohorts were matched 2:1 by age and body mass index. Multivariate regressions were used to compare Hip Outcome Score, Activities of Daily Living subscale (HOS-ADL) and Sports subscale (HOS-SS) scores and modified Harris Hip Score (mHHS) between the cohorts at 2-year follow-up. Binomial regression analysis was used to determine predictors of achieving minimal clinically important difference (MCID) and patient-acceptable symptom state (PASS). There was no statistical difference in age and BMI between the BHD revision (29.1 ± 8.8years; 25.5 ±3.58kg/m2), BHD nonrevision (28.9 ± 8.5years; 24.6 ± 3.1kg/m2), and non-BHD revision (29.15 ± 8.6years; 25.01 ±3.2kg/m2) cohorts. There were no statistically significant differences in 2-year clinical outcomes between BHD revision patients and either BHD primary or non-BHD revision patient groups, but BHD revision patients were significantly less likely to achieve PASS for HOS-SS compared with BHD primary and non-BHD revision groups (P= .047 and P= .031, respectively). Surgeons should exercise caution when indicating patients for revision hip arthroscopy with BHD. Although the current study lacks statistical power, the available data suggest that patients undergoing revision surgery with BHD may still experience clinical improvement but be less likely to achieve PASS metrics for several patient-reported outcomes at 2-year follow up. III, case-control study.

The Pull Test: A Dynamic Test to Confirm Hip Microinstability

PurposeTo define a distraction distance (pull length) cut-off that would differentiate those patients with hip microinstability and those without the disorder, called the Pull-Out Test.MethodsIn total, 100 consecutive patients undergoing hip arthroscopy were included in the study. Patients were separated into a hip microinstability group (HMI) and non-hip microinstability group (NHI) based on the results of Beighton's score, the abduction–extension–external rotation test, hip extension–external rotation examination, and the prone instability test. Inclusion criteria were patients with an magnetic resonance imaging-proven labral tear who did not respond to conservative treatment and underwent hip arthroscopy. Exclusion criteria included those patients undergoing revision hip arthroscopy, had a previous surgery on the ipsilateral hip, or had severe arthritis in the hip. The Pull-Out Test was performed before surgery with the hip in 30° of abduction and the foot in 30° of external rotation. A blinded examiner places gross axial traction on the leg until a firm end point is reached. The distraction distance between the femoral head and acetabulum is the pull length.ResultsIn total, 32 patients made up the HMI group whereas 68 patients were in the NHI group. The average pull length for the NHI group was 0.9 ± 0.1 cm and 1.7 ± 0.4 cm for the HMI group (P < .001). Subtracting the standard deviation from the HMI group average, when defined a cut off for hip microinstability as 1.3 cm. Using this value, we found the Pull-Out Test to have a sensitivity of 0.91 and specificity of 0.96. The positive predictive value for the Pull Test was 0.91 and the negative predictive value 0.97.ConclusionsThe Pull-Out Test is a useful test in identifying and confirming the presence of hip microinstability in patients undergoing hip arthroscopy. A pull-length of 1.3 cm or greater is consistent with the presence of microinstability with a specificity of 94% and a sensitivity of 96%.Level of EvidenceLevel IV, diagnostic, case-control study.

Independent Risk Factors for Revision Surgery or Conversion to Total Hip Arthroplasty After Hip Arthroscopy: A Review of a Large Statewide Database From 2011 to 2012

To use a large heterogeneous population to identify independent risk factors for revision surgery or conversion to total hip arthroplasty (THA) after hip arthroscopy. The New York Statewide Planning and Research Cooperative System database was queried from 2011 through 2012 to identify patients undergoing hip arthroscopy. All patients aged 18years or older who underwent hip arthroscopy according to Current Procedural Terminology coding were included. We chose to divide surgical volume into tertiles for the purposes of statistical analysis. Longitudinal analysis for a minimum of 2years was performed to determine risk factors for revision surgery or conversion to THA. We identified 3,957 patients. The mean age was 35.8years (standard deviation, 13.1years). After a minimum follow-up period of 2years, the overall failure rate was 9.6%: 3.7% of patients underwent revision hip arthroscopy at an average of 15.8months, whereas 5.9% underwent conversion to THA at 14.7months. Index surgery performed by surgeons in the third tertile of surgical volume (<40 cases per annum) was an independent risk factor for revision (odds ratio [OR], 1.71; P= .001), as well as conversion to THA (OR, 1.90; P < .001). Female patients (OR, 1.8; P < .001), older patients (OR, 3.4; P < .001), and patients with a history of obesity (OR, 5.6; P < .001) underwent conversion to THA at significantly higher rates than other patients. Young patients (OR, 4.4; P < .001) and female patients (OR, 1.6; P < .001) were more likely to undergo revision hip arthroscopy. Our analysis of 3,957 patients found that female sex, age under 40years, absence of a labral repair, and index procedure performed by a low-volume surgeon were independent risk factors for revision hip arthroscopy. Age over 60years, index procedure performed by a low-volume surgeon, female sex, obesity, and the presence of pre-existing arthritis were risk factors for THA conversion. Level III, case-control study.

Outcomes of Revision Hip Arthroscopy: 2-Year Clinical Follow-up

To evaluate clinical outcomes, pain, and patient satisfaction following revision hip arthroscopy with a minimum2-year follow-up. From April 2008 to October 2011, data were prospectively collected on all patients undergoing revision hip arthroscopy. All patients were assessed pre- and postoperatively with 4 patient-reported outcome (PRO) measures: the modified Harris hip score (mHHS), nonarthritic hip score (NAHS), hip outcome score-activities of daily living (HOS-ADL), and hip outcome score-sport-specific subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. The number of patients who underwent subsequent revision arthroscopy or total hip arthroplasty during the study period is also reported. Eighty-seven patients underwent revision hip arthroscopy during the study period. Seventy (80.5%) patients were included in our study. Average follow-up time was 28months (range, 20 to 47.4months). In terms of residual femoroacetabular impingement morphology, 45.7% of patients had preoperative alpha angles ≥ 55°, and 7.14% of patients had a lateral center-edge angle ≥ 40°. The score improvement from preoperative to 2-year follow-up was 57.84 to 73.65 for mHHS, 62.79 to 83.04 for HOS-ADL, 37.33 to 54.93 for HOS-SSS, and 55.65 to 70.79 for NAHS. VAS decreased from 6.72 to 4.08. All scores demonstrated statistically significant improvement (P < .001). Overall patient satisfaction was 7.67. Our success rate was 74.58%. Ten (14.29%) patients underwent total hip arthroplasty during the study period. Our hip survivorship was 85.7%. Five (7.14%) patients underwent secondary revision hip arthroscopy during the study period. We found an overall minor complication rate of 10%. Revision hip arthroscopy for all procedures performed on aggregate has improved clinical outcomes for all PROs, high survivorship, and high patient satisfaction scores at short-term follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty and the potential for revision surgery. Level IV retrospective case series.

Does Revision Hip Arthroscopy Result in Improved Clinical Outcomes? - A 2-Year Clinical Follow-up On All Revision Hip Arthroscopies Performed at a High Volume Referral Center

Objectives:The purpose of this study was to evaluate clinical outcomes, pain, and patient satisfaction following revision hip arthroscopy at a high volume referral center with a minimum 2-year follow-up.Methods:During the study period, April 2008 to October 2011, data was prospectively collected on all patients undergoing revision hip arthroscopy. All patients were assessed pre- and post-operatively with 4 patient-reported outcome (PRO) measures: 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 Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10.Results:Eighty-seven patients underwent revision hip arthroscopy during the study period. Seventy (80.5%) patients were included in our study. In terms of residual FAI morphology, 45.7% of patients had preoperative alpha angles ≥55 degrees and 7.14% of patients had a LCEA ≥40 degrees. The score improvement from preoperative to 2-year follow-up was 57.84 to 73.65 for mHHS, 62.79 to 83.04 for HOS-ADL, 37.33 to 54.93 for HOS-SSS, 55.65 to 70.79 for NAHS. VAS decreased from 6.72 preoperatively to 4.08 postoperatively. All scores demonstrated statistically significant improvement (P<.001). Overall patient satisfaction was 7.67. Our success rate was 74.58% for primary revision hip arthroscopy and 100% for secondary revision hip arthroscopy. Ten (14.29%) patients underwent total hip arthroplasty during the study period. Our hip survivorship was 85.7%. Five (7.14%) patients underwent secondary revision hip arthroscopy during the study period. We found an overall minor complication rate of 10%.Conclusion:Revision hip arthroscopy for all procedures performed on aggregate has excellent clinical outcomes for all PROs and patient satisfaction scores at short-term follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty, and the potential for revision surgery.

Outcomes of 1038 Hip Arthroscopies

Objectives:The purpose of this study was to evaluate clinical outcomes, pain, and patient satisfaction following all hip arthroscopies performed by a single surgeon at a high volume referral center with a mean 2-year follow-up.Methods:During the study period, February 2008 to June 2012, data were collected on all patients undergoing hip arthroscopy. All patients were assessed pre- and post-operatively with 4 patient-reported outcome (PRO) measures: 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 Subscales (HOS-SSS). Pain was estimated on the visual analog scale (VAS). Patient satisfaction was measured on a scale from 0 to 10. The number of patients who underwent revision arthroscopy, total hip arthroplasty, or a resurfacing procedure during the study period is also reported for primary and revision hip arthroscopies.Results:One thousand and thirty eight patients underwent hip arthroscopy during the study period. The score improvement from preoperative to 2-year follow-up was 60.9 to 77.6 for mHHS, 62.8 to 78.9 for HOS-ADL, 40.0 to 63.43 for HOS-SSS, 57.4 to 76.2 for NAHS. VAS decreased from 5.86 preoperatively to 3.15 postoperatively. All scores demonstrated statistically significant improvement (p<0.001). Overall patient satisfaction was 7.57. One hundred and seven (10.3%) patients underwent revision hip arthroscopy during the study period. Sixty-three (6.07%) patients underwent either total hip arthroplasty (THA) or hip resurfacing (HR) procedures during the study period. Of these, 51 (5.48%) were after primary hip arthroscopies and 12 (11.2%) were after revision hip arthroscopies suggesting a relative risk of 2.05 for a THA/HR after revision procedures. Figure 1 shows a Kaplan-Meier survivorship curve for patients who underwent primary and revision hip arthroscopies with THA/HR. The overall complication rate was 5.5%.Conclusion:Hip arthroscopy for all indications results in improved clinical outcomes, decreased pain, and high satisfaction at a mean 2-year follow-up. Patients should be counseled regarding the potential progression of degenerative change leading to arthroplasty, and the potential for revision surgery.