Stratified care in hip arthroscopy: can we predict successful and unsuccessful outcomes? Development and external temporal validation of multivariable prediction models.

OBJECTIVE: Although hip arthroscopy is a widely adopted treatment option for hip-related pain, it is unknown whether preoperative clinical information can be used to assist surgical decision-making to avoid offering surgery to patients with limited potential for a successful outcome. We aimed to develop and validate clinical prediction models to identify patients more likely to have an unsuccessful or successful outcome 1 year post hip arthroscopy based on the patient acceptable symptom state. METHODS: Patient records were extracted from the Danish Hip Arthroscopy Registry (DHAR). A priori, 26 common clinical variables from DHAR were selected as prognostic factors, including demographics, radiographic parameters of hip morphology and self-reported measures. We used 1082 hip arthroscopy patients (surgery performed 25 April 2012 to 4 October 2017) to develop the clinical prediction models based on logistic regression analyses. The development models were internally validated using bootstrapping and shrinkage before temporal external validation was performed using 464 hip arthroscopy patients (surgery performed 5 October 2017 to 13 May 2019). RESULTS: The prediction model for unsuccessful outcomes showed best and acceptable predictive performance on the external validation dataset for all multiple imputations (Nagelkerke R2 range: 0.25-0.26) and calibration (intercept range: -0.10 to -0.11; slope range: 1.06-1.09), and acceptable discrimination (area under the curve range: 0.76-0.77). The prediction model for successful outcomes did not calibrate well, while also showing poor discrimination. CONCLUSION: Common clinical variables including demographics, radiographic parameters of hip morphology and self-reported measures were able to predict the probability of having an unsuccessful outcome 1 year after hip arthroscopy, while the model for successful outcome showed unacceptable accuracy. The externally validated prediction model can be used to support clinical evaluation and shared decision making by informing the orthopaedic surgeon and patient about the risk of an unsuccessful outcome, and thus when surgery may not be appropriate.

Femoroacetabular impingement syndrome and labral injuries: grading the evidence on diagnosis and non-operative treatment-a statement paper commissioned by the Danish Society of Sports Physical Therapy (DSSF).

This statement summarises and appraises the evidence on diagnostic tests and clinical information, and non-operative treatment of femoroacetabular impingement (FAI) syndrome and labral injuries. We included studies based on the highest available level of evidence as judged by study design. We evaluated the certainty of evidence using the Grading of Recommendations Assessment Development and Evaluation framework. We found 29 studies reporting 23 clinical tests and 14 different forms of clinical information, respectively. Restricted internal hip rotation in 0° hip flexion with or without pain was best to rule in FAI syndrome (low diagnostic effectiveness; low quality of evidence; interpretation of evidence: may increase post-test probability slightly), whereas no pain in Flexion Adduction Internal Rotation test or no restricted range of motion in Flexion Abduction External Rotation test compared with the unaffected side were best to rule out (very low to high diagnostic effectiveness; very low to moderate quality of evidence; interpretation of evidence: very uncertain, but may reduce post-test probability slightly). No forms of clinical information were found useful for diagnosis. For treatment of FAI syndrome, 14 randomised controlled trials were found. Prescribed physiotherapy, consisting of hip strengthening, hip joint manual therapy techniques, functional activity-specific retraining and education showed a small to medium effect size compared with a combination of passive modalities, stretching and advice (very low to low quality of evidence; interpretation of evidence: very uncertain, but may slightly improve outcomes). Prescribed physiotherapy was, however, inferior to hip arthroscopy (small effect size; moderate quality of evidence; interpretation of evidence: hip arthroscopy probably increases outcome slightly). For both domains, the overall quality of evidence ranged from very low to moderate indicating that future research on diagnosis and treatment may alter the conclusions from this review.

High incidence of lost workdays in patients with subacromial impingement syndrome.

INTRODUCTION: Loss of workdays is the main societal cost related to shoulder disorders with nine lost workdays per six months on average. The most common shoulder disorder is subacromial impingement syndrome (SIS), but it remains unknown if SIS is also a leading cause of shoulder-related loss of worktime. We aimed to investigate the incidence of workdays lost due to SIS during the six months following a SIS diagnosis in specialised care. METHODS: Among 157 consecutive patients diagnosed with SIS in secondary care, 129 (82%) completed a structured six-month follow-up interview. Job status, average working hours and sick leave due to SIS were recorded. Only patients holding a job (n = 58) and patients who lost their job due to SIS (n = 8) were considered to be at risk of losing workdays, leaving 66 patients in the at-risk group. The number of lost workhours due to SIS was calculated and normalised to full-time workdays, and incidences of lost workdays were estimated using Poisson regressions. RESULTS: In total, 1,781 workdays were lost. The mean number of lost workdays per six months was 27 days (95% confidence interval (CI): 18-40) for patients at risk (n = 66), corresponding to 14 days on average (95% CI: 9-21 days) for the entire cohort (n = 129). A total of 33 patients were responsible for all loss of workdays. CONCLUSIONS: We found that an average of 27 workdays (> 5 work weeks) were lost due to SIS during the first six months after the diagnosis in patients who were otherwise fit to work. This is three times higher than the nine days previously reported for shoulder problems in general, indicating that productivity loss in patients diagnosed with SIS is a major concern. FUNDING: none. TRIAL REGISTRATION: not relevant.