Sex Differences in Clinical Outcomes Following Surgical Treatment of Femoroacetabular Impingement.

BACKGROUND: Sex-based differences in clinical outcomes following surgical treatment of femoroacetabular impingement remain largely uncharacterized; this prospective, multicenter study evaluated these differences both directly and adjusted for covariates. METHODS: Hips undergoing surgical treatment of symptomatic femoroacetabular impingement were prospectively enrolled in a multicenter cohort. Patient demographics, radiographic parameters, intraoperatively assessed disease severity, and history of surgical procedures, as well as patient-reported outcome measures, were collected preoperatively and at a mean follow-up of 4.3 years. A total of 621 (81.6%) of 761 enrolled hips met the minimum 1 year of follow-up and were included in the analysis; 56.7% of analyzed hips were female. Univariate and multivariable statistics were utilized to assess the direct and adjusted differences in outcomes, respectively. RESULTS: Male hips had greater body mass index and larger α angles. Female hips had significantly lower preoperative and postoperative scores across most patient-reported outcome measures, but also had greater improvement from preoperatively to postoperatively. The preoperative differences between sexes exceeded the threshold for the minimal clinically important difference of the modified Harris hip score (mHHS) and all Hip disability and Osteoarthritis Outcome Score (HOOS) domains except quality of life. Preoperative sex differences in mHHS, all HOOS domains, and Short Form-12 Health Survey physical function component score were greater than the postoperative differences. A greater proportion of female hips achieved the minimal clinically important difference for the mHHS, but male hips were more likely to meet the patient acceptable symptom state for this outcome. After adjusting for relevant covariates with use of multiple regression analysis, sex was not identified as an independent predictor of any outcome. Preoperative patient-reported outcome scores were a strong and highly significant predictor of all outcomes. CONCLUSIONS: Significant differences in clinical outcomes were observed between sexes in a large cohort of hips undergoing surgical treatment of femoroacetabular impingement. Despite female hips exhibiting lower baseline scores, sex was not an independent predictor of outcome or reoperation. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Low Self-Efficacy and High Kinesiophobia Are Associated With Worse Function in Patients With Femoroacetabular Impingement Syndrome.

CONTEXT: Femoroacetabular impingement syndrome (FAIS) is a painfully debilitating hip condition disproportionately affecting active individuals. Mental health disorders are an important determinant of treatment outcomes for individuals with FAIS. Self-efficacy, kinesiophobia, and pain catastrophizing are psychosocial factors that have been linked to inferior outcomes for a variety of orthopedic conditions. However, these psychosocial factors and their relationships with mental health disorders, pain, and function have not been examined in individuals with FAIS. OBJECTIVE: (1) To examine relationships between self-efficacy, kinesiophobia, pain catastrophizing, pain, and function in patients with FAIS and (2) to determine if these variables differ between patients with and without a self-reported depression and/or anxiety. DESIGN: Cross-sectional. SETTING: University health center. PARTICIPANTS: Fifty-one individuals with FAIS (42 females/9 males; age 35.7 [11.6] y; body mass index 27.1 [4.9] kg/m2). MAIN OUTCOME MEASURES: Participants completed the Pain Self-Efficacy Questionnaire, Tampa Scale for Kinesiophobia, Pain Catastrophizing Scale, visual analog scale for hip pain at rest and during activity, and the 12-item International Hip Outcome Tool. Self-reported depression and/or anxiety were recorded. The relationships between psychosocial factors, pain, and function were examined using Spearman rank-order correlations. Independent t tests and Mann-Whitney U tests were used to evaluate the effect of self-reported depression and/or anxiety on psychosocial factors, pain and function. RESULTS: The 12-item International Hip Outcome Tool was correlated with pain during activity (ρ = -.57, P ≤ .001), Tampa Scale for Kinesiophobia (ρ = -.52, P ≤ .001), and Pain Self-Efficacy Questionnaire (ρ = .71, P ≤ .001). The Pain Self-Efficacy Questionnaire was also correlated with pain at rest (ρ = -.43, P = .002) and pain during activity (ρ = -.46, P = .001). Individuals with self-reported depression and/or anxiety (18/51; 35.3%) had worse self-efficacy and pain catastrophizing (P ≤ .01). CONCLUSION: Self-reported depression and/or anxiety, low self-efficacy, and high kinesiophobia were associated with more hip pain and worse function for patients with FAIS. These findings warrant further examination including psychosocial treatment strategies to improve the likelihood of a successful clinical outcome for this at-risk population.

Depression and Anxiety Are Associated With Increased Health Care Costs and Opioid Use for Patients With Femoroacetabular Impingement Undergoing Hip Arthroscopy: Analysis of a Claims Database.

PURPOSE: To determine if opioid use and health care costs in the year before and following hip arthroscopy for femoroacetabular impingement (FAI) differ between those with or without depression or anxiety. METHODS: Using the Truven Health Marketscan database, FAI patients who underwent hip arthroscopy between October 2010 and December 2015 were identified (Current Procedural Terminology codes 29914 [femoroplasty], 29915 [acetabuloplasty], and/or 29916 [labral repair]). Patients were excluded if they had incomplete coverage for 1 year either before or following surgery. The number of patients with 1 or more claims related to depression or anxiety during the year before surgery was quantified (International Statistical Classification Diseases and Related Health-9 codes 296, 298, 300, 309, 311). Health care costs in the year before and following hip arthroscopy were compared between those with or without depression or anxiety. We also compared the number of patients in each group who filled a narcotic pain prescription within 180 days before surgery as well as >60 or >90 days after hip arthroscopy. RESULTS: Depression or anxiety claims were seen in 5,208/14,830 patients (35.1%) before surgery. A significantly greater proportion of those with preoperative depression or anxiety filled opioid-related prescriptions in the 6 months before surgery (36.2% vs 25.6%, P < .0001) and both >60 days (31.3% vs 24.7%, P < .0001) and >90 days after surgery (29.5% vs 23.4%, P < .0001). The group with preoperative depression or anxiety had significantly greater health care costs both before ($8,775 vs $5,674, P < .0001) and following surgery ($5,287 vs $3,908, P < .0001). CONCLUSIONS: Both before and following hip arthroscopy, opioid use and health care costs were significantly greater for FAI patients with comorbid depression or anxiety. LEVEL OF EVIDENCE: Level III, retrospective comparative therapeutic study.

The Effect of Psychological Impairment on Outcomes in Patients With Prearthritic Hip Disorders: A Systematic Review and Meta-analysis.

BACKGROUND: Recent studies have suggested that mental health disorders negatively affect postoperative outcomes in patients with femoroacetabular impingement (FAI). However, the outcome measures reported and the effect sizes have varied. Furthermore, it is unknown whether similar effects are present in young adults with other hip disorders such as acetabular dysplasia. PURPOSE: To synthesize current evidence regarding the effect of baseline psychological impairment on postintervention outcomes in patients with prearthritic hip disorders. STUDY DESIGN: Systematic review and meta-analysis. METHODS: In February 2019, the Ovid Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and ClinicalTrials.gov databases were searched for longitudinal studies that evaluated the effect of baseline psychological impairment (such as depression or anxiety) on a postintervention clinical outcome in patients with prearthritic hip disorders including FAI, acetabular dysplasia, and/or acetabular labral tears. Descriptive measures of study quality and bias were recorded, and studies that reported statistically comparable outcomes were analyzed in meta-analyses through use of random effects models. RESULTS: We identified 12 eligible studies, all of which specifically evaluated patients with FAI after hip arthroscopy. No eligible studies described patients with acetabular dysplasia. Of the included studies, 8 studies reported odds ratios (ORs). The other 4 studies reported mean postoperative scores on patient-reported outcome measures (PROMs), all of which were scored from 0 to 100, with higher numbers being favorable. Patients with psychological impairment were less likely to achieve a favorable outcome after arthroscopy (OR, 0.74; 95% CI, 0.62 to 0.88; P < .001), and they reported worse postoperative PROM scores compared with nonimpaired patients (weighted mean difference, -20.2 points; 95% CI, -32.9 to -7.5; P < .001). CONCLUSION: Baseline psychological impairment is associated with clinically significantly worse outcomes in patients with femoroacetabular impingement who undergo hip arthroscopy. More standardized reporting would facilitate improved understanding of this important, potentially modifiable risk factor. REGISTRATION: CRD42019124836 (PROSPERO).

Do psychological factors or radiographic severity play a role in the age of onset in symptomatic developmental dysplasia of hip and femoroacetabular impingement syndrome?

BACKGROUND: Age of onset in symptomatic developmental dysplasia of the hip (DDH) and femoroacetabular impingement syndrome (FAIS) varies. The purpose of this study was to investigate whether psychological factors, radiographic, and clinical variables were related to age of onset of hip pain in DDH and FAIS. METHODS: We collected demographic, clinical, and radiographic data on 56 DDH and 84 FAIS patients. Each was diagnosed based on radiographic findings and clinical history. Age of onset was operationalized by subtracting patient reported duration of symptoms from patient age at presentation. Pain catastrophizing (PCS) and depression were assessed with the pain catastrophizing scale and hospital anxiety and depression scale (HADS), respectively. Multiple linear regression modeling, with Lasso variable selection, was implemented. RESULTS: Pain catastrophizing, anxiety, and depression were not significantly related to age of DDH onset (p-values > 0.27) or age of FAIS onset (p-values > 0.29). LASSO-penalized linear regression revealed alpha Dunn angle, Tonnis grade, prior hip surgery, WOMAC pain score, and iHOT total score were associated with age of onset in FAIS (Adjusted R2 = 0.3099). Lateral center edge angle (LCEA), alpha frog angle, Tonnis grade, SF12 physical functioning, and body mass index (BMI) were associated with age of DDH onset (Adjusted R2 = 0.3578). CONCLUSIONS: Psychological factors, as measured by PCS and HADS, were not associated with age of onset in DDH or FAIS. Functional impairment as measured by WOMAC pain and impaired active lifestyle as measured by iHOT were found to affect age of FAIS onset. For DDH, impaired physical functioning and increasing BMI were found to be associated with age of onset. Severity of the disease, as measured radiographically by LCEA and alpha Dunn angle, was also found to be associated with earlier age of onset in DDH and FAIS, respectively. A patient's radiographic severity may have more of a relationship to the onset of pain than physiologic factors.

Pain catastrophizing, anxiety, and depression in hip pathology.

AIMS: Psychological factors play a critical role in patient presentation, satisfaction, and outcomes. Pain catastrophizing, anxiety, and depression are important to consider, as they are associated with poorer outcomes and are potentially modifiable. The aim of this study was to assess the level of pain catastrophizing, anxiety, and depression in patients with a range of hip pathology and to evaluate their relationship with patient-reported psychosocial and functional outcome measures. PATIENTS AND METHODS: Patients presenting to a tertiary-centre specialist hip clinic were prospectively evaluated for outcomes of pain catastrophizing, anxiety, and depression. Validated assessments were undertaken such as: the Pain Catastrophizing Scale (PCS), the Hospital Anxiety Depression Scale (HADS), and the 12-Item Short-Form Health Survey (SF-12). Patient characteristics and demographics were also recorded. Multiple linear regression modelling, with adaptive least absolute shrinkage and selection operator (LASSO) variable selection, was used for analysis. RESULTS: A total of 328 patients were identified for inclusion, with diagnoses of hip dysplasia (DDH; n = 50), femoroacetabular impingement (FAI; n = 55), lateral trochanteric pain syndrome (LTP; n = 23), hip osteoarthrosis (OA; n = 184), and avascular necrosis of the hip (AVN; n = 16) with a mean age of 31.0 years (14 to 65), 38.5 years (18 to 64), 63.7 years (20 to 78), 63.5 years (18 to 91), and 39.4 years (18 to 71), respectively. The percentage of patients with abnormal levels of pain catastrophizing, anxiety, or depression was: 22.0%, 16.0%, and 12.0% for DDH, respectively; 9.1%, 10.9%, and 7.3% for FAI, respectively; 13.0%, 4.3%, and 4.3% for LTP, respectively; 21.7%, 11.4%, and 14.1% for OA, respectively; and 25.0%, 43.8%, and 6.3% for AVN, respectively. HADS Anxiety (HADSA) and Hip Disability Osteoarthritis Outcome Score Activities of Daily Living subscale (HOOS ADL) predicted the PCS total (adjusted R2 = 0.4599). Age, HADS Depression (HADSD), and PCS total predicted HADSA (adjusted R2 = 0.4985). Age, HADSA, patient's percentage of perceived function, PCS total, and HOOS Quality of Life subscale (HOOS QOL) predicted HADSD (adjusted R2 = 0.5802). CONCLUSION: Patients with hip pathology may exhibit significant pain catastrophizing, anxiety, and depression. Identifying these factors and understanding the impact of psychosocial function could help improve patient treatment outcomes. Perioperative multidisciplinary assessment may be a beneficial part of comprehensive orthopaedic hip care. Cite this article: Bone Joint J 2019;101-B:800-807.

Patients' Expectations of Hip Preservation Surgery: A Survey Study.

PURPOSE: To administer the Hip Preservation Surgery Expectations Survey to a large sample of patients to ascertain the prevalence of their preoperative expectations and to assess expectations in terms of demographic and clinical characteristics. METHODS: Consecutive patients were enrolled if they were ≥18 years old/spoke English and excluded if they had prior hip surgery/degenerative changes Tönnis ≥2. Patients completed the 21-item survey addressing the amount of improvement expected for each item (number of items and an overall score were determined) and the International Hip Outcome Tool (iHOT; hip score determined). Analyses included multivariable regression with survey score and number of expectations as dependent variables. Subanalyses considered collegiate/professional, competitive, and recreational sports level. RESULTS: Three hundred two patients participated, with a mean age of 32; 270 (89%) had cam impingement, 72 (24%) had symptoms <6 months, and mean iHOT score was 41. One hundred twenty patients (40%) selected all 21 survey items, 112 (37%) selected 18 to 20, and 70 (23%) selected ≤17 items. In multivariable analysis, younger age (odds ratio [OR] = 1.3; P = .02), symptoms <6 months (OR = 1.3; P = .03), and worse iHOT score (OR = 2.5; P = .0001) were associated with selecting more items. The mean survey score was 80 (range, 31-100). In multivariable analysis, younger age (P = .05), symptoms <6 months (P = .01), and worse iHOT score (P = .03) were associated with greater survey scores. Collegiate/professional athletes selected more items (P = .01) and were more likely to select improvement in sports performance (OR = 7.5; P = .001), achievement of athletic potential (OR = 3.7; P = .002), and maintaining options for more demanding future activities (OR = 2.7; P = .01). CONCLUSIONS: Patients had multiple expectations for marked improvement in current and future physical function and psychological well-being. Younger patients, shorter symptom duration, and worse hip-specific functional status were associated with greater expectations. Understanding patients' expectations can guide preoperative education regarding realistic expectations for recovery and long-term outcome. CLINICAL RELEVANCE: Patients' preoperative expectations vary according to demographic and clinical characteristics as measured in a survey study.

Arthroscopic Acetabular Labral Repair in Patients Over the Age of 60 Years: A Matched Case-Control Study.

PURPOSE: To report the results of labral repair in a population of patients older than 60 years and compare these with a matched population of younger adults. METHODS: We compared 21 consecutive patients older than 60 years undergoing labral repair with minimum 1-year follow-up with a contemporaneous group of 21 patients aged 18 to 55 years matched for sex, degree of chondral damage, and associated femoroacetabular impingement or dysplasia. RESULTS: Follow-up averaged 18.9 months (range, 12-24 months). The average age in the study group was 63.2 years (range, 61-71 years), and 20 patients had femoroacetabular impingement whereas 1 had dysplasia. Of these patients, 19 had acetabular articular damage (grade IV in 2, grade III in 11, grade II in 5, and grade I in 1) and 6 had femoral changes (grade IV in 1 and grade III in 5). The average age in the control group was 35.8 years (range, 20-54 years). We found average improvements of 28.1 points for the modified Harris Hip Score and 37.5 points for the International Hip Outcome Tool score within the study group and 21.2 points for the modified Harris Hip Score and 37.1 points for the International Hip Outcome Tool score within the control group. No statistically significant difference between the 2 groups was noted in the amount of improvement, with statistically and clinically significant improvements noted in both. Two study group patients underwent total hip arthroplasty (THA) at an average of 10 months, with 1 control group THA at 11 months. All 3 patients with conversion to THA had combined grade IV acetabular and grade III femoral damage. No repeated arthroscopies were performed and no complications occurred in either group. CONCLUSIONS: Patients older than 60 years can benefit from arthroscopic labral repair with improved outcomes, a modest rate of conversion to THA, and a small risk of complications. The results are comparable to those of younger adults. Combined bipolar grade IV and grade III articular damage may be a harbinger of conversion to THA regardless of age. LEVEL OF EVIDENCE: Level III, comparative therapeutic trial.

The Presence of a Psychiatric Condition is Associated With Undergoing Hip Arthroscopy for Femoroacetabular Impingement: A Matched Case-Controlled Study.

BACKGROUND: We sought to examine the association between having a psychiatric condition and undergoing hip arthroscopy for femoroacetabular impingement (FAI). METHODS: A matched case-control study was performed to control for age and gender. All patients over 16 years of age with FAI treated with hip arthroscopy by a single surgeon were randomly matched to a patient of the same age and gender undergoing knee arthroscopy for any diagnosis other than infection by the same surgeon during the same period. Conditional logistic regression was used to compare the odds of having a psychiatric condition between groups. RESULTS: Fifty-one matched pairs of patients undergoing hip and knee arthroscopy were identified. Each group contained 35 females (69%) and had a mean age of 33.6 years. Of the 51 hip arthroscopy cases, 23 (45.1%) had a psychiatric condition. Of the 51 knee arthroscopy controls, 11 (21.6%) had a psychiatric condition. Patients undergoing hip arthroscopy were statistically significantly more likely to have a psychiatric condition compared to patients undergoing knee arthroscopy with an odds ratio of 3.4 (95% confidence interval 1.3-9.2, P < .01). CONCLUSION: There was a strong association between having a psychiatric condition and undergoing hip arthroscopy for FAI. More research should be done investigating psychiatric conditions among patients with FAI and whether this association can identify strategies to optimize patient outcomes.

Femoroacetabular Impingement Randomised controlled Trial (FIRST) - a multi-centre randomized controlled trial comparing arthroscopic lavage and arthroscopic osteochondroplasty on patient important outcomes and quality of life in the treatment of young adult (18-50 years) femoroacetabular impingement: a statistical analysis plan.

BACKGROUND: The research objectives of the Femoroacetabular Impingement Randomised controlled Trial (FIRST) are to assess whether surgical correction of the hip impingement morphology (arthroscopic osteochondroplasty) with or without labral repair, in adults aged 18-50 years diagnosed with non-arthritic femoroacetabular impingement (FAI), provides decreased pain and improved health-related quality of life at 12 months compared to arthroscopic lavage of the hip joint. This article describes the statistical analysis plan for the FIRST trial. METHODS/DESIGN: FIRST is an ongoing multi-centre, blinded randomised controlled trial of 220 patients who have been diagnosed with FAI and are optimized for surgical intervention. This article describes the overall analysis principles, including how participants will be included in each analysis, the presentation of the results, adjustments for covariates, the primary and secondary outcomes and their respective analyses. In addition, we will present the planned sensitivity and subgroup analyses. DISCUSSION: Our rationale for FIRST is based upon (1) an epidemic of FAI surgery with resultant increased healthcare costs over that last decade, (2) worldwide disparity in perceptions about its utility, and (3) consensus that definitive evidence for or against surgical approaches is lacking. TRIAL REGISTRATION: ClinicalTrials.gov, NCT01623843 . Registered on 20 June 2012.

Preoperative Symptoms in Femoroacetabular Impingement Patients Are More Related to Mental Health Scores Than the Severity of Labral Tear or Magnitude of Bony Deformity.

BACKGROUND: The purpose of this study was to determine the relationships between patient factors, mental health status, the condition of the local tissue, magnitude of bony deformity, and preoperative symptoms in a series of femoroacetabular impingement (FAI) patients. METHODS: From our prospective outcomes registry, we identified 64 patients with arthroscopically-treated labral tears and cam deformities. We assessed the correlations between patient factors (age, sex, body mass index, level of education), surgical findings (size of labral tear, presence of chondral lesions), mental health factors (VR-12 mental component score [MCS], depression, and preoperative use of psychotropic and/or opioid drugs), magnitude of FAI deformity (alpha and lateral center edge angles), and preoperative hip dysfunction and osteoarthritis outcome score (HOOS) subscales. Patient factors, surgical and radiographic findings, and preoperative HOOS scores were compared between patients with low and high MCS. RESULTS: Neither hip pathology nor patient-related factors significantly correlated with HOOS scores. On the contrary, MCS significantly correlated with HOOS symptom (ρ = 0.45, P < .001) and pain scores (ρ = 0.52, P < .001). Low MCS patients had significantly lower preoperative scores for all 5 HOOS subscales (P ≤ .002) and more frequent chondral lesions and comorbid depression (P ≤ .01). CONCLUSION: Symptom severity was significantly more related to mental health status than either the size of labral tear or FAI deformity. Patients with low MCS had significantly worse preoperative pain and self-reported function, and a greater prevalence of concomitant chondral lesions. Future studies are necessary to determine if earlier surgical treatment or preoperative psychological and/or pain coping interventions may improve outcomes for those with low MCS.

[Mini-open Approach Shows Good Results in Treatment of Femoroacetabular Impingement]. / Mini-open-Verfahren zeigt gute Ergebnisse in der Therapie des femoroazetabulären Impingements.

Background Femoroacetabular impingement (FAI) describes a painful, abnormal (bony) contact between the femoral neck and acetabulum, which, if left untreated, contributes to early osteoarthritis (OA) of the hip. Despite its flat learning curve and long operation times, hip arthroscopy has been used increasingly often in recent years in the surgery of femoroacetabular impingement. The mini-open technique (MOT) offers a possible alternative that addresses the abnormal morphological prominence and allows minimally invasive clearance of hip motion. There is still a lack of information on the influence of the greater degree of soft tissue intrusion inherent to the mini-open approach. Therefore we decided to evaluate the medium-term outcome of the mini-open technique and to compare the results to those of the arthroscopic technique reported in the literature. Patients, Material und Methods 99 patients (105 hips, 40 women, 59 men) underwent mini-open surgical treatment for FAI between 2005 and 2012 and were followed-up for an average of 40.5 months. The evaluation focused on the pre- and postoperative pain intensity (NRS: numeric rating scale), the clinical and functional outcomes such as ROM (range of motion), HOS (Hip Outcome Score) and mHHS (modified Harris Hip Score), changes in athletic behaviour and the satisfaction of the patients. Radiological analysis (α-angle, anterior head-neck-offset (HNO), head-neck-offset ratio, ossification, grade of OA) was performed using preoperative, immediate postoperative as well as follow-up radiographs. Finally our results were compared to those reported for the arthroscopic technique in the literature. Results The average pain level decreased from 6.5 ± 2.3 to 2.3 ± 2.6 (p < 0.001). 80 % (84) confirmed a mean postoperative pain-free period of 29.5 months (2-103 months), and 52.4 % (55) were still almost pain-free by the time of the final follow-up. The mHHS increased from 68.2 ± 13.5 to 85.2 ± 18.2 (p < 0.001). The HOS-ADL (ADL: activities of daily life) was 82.2 % ± 19.7 and the HOS-sport was 69.7 % ± 27.9 at the final follow-up. At the time of the last follow-up, 93 % of the preoperatively active patients (n = 84) returned to athletic activities (n = 78). In a comparison of athletic behaviour, significantly fewer patients were performing high-impact and more patients were performing low-impact sports after surgery. Flexion (113°±16 to 117°±16) and internal rotation (12°±8 to 25°±12) improved significantly. α-angle reduction from 62°±11 to 42°± 9 (p < 0.01) was observed. The HNO increased from 3.8 mm ± 3.2 to 10.7 mm ± 3.2. In 17.6 % of the cases, progression of OA was noticed. Patients with initial OA Kellgren ≥ 2 showed significantly worse outcome than those without OA. Conclusion MOT is a safe and effective alternative for treating FAI. It leads to recovery of pain-free hip function in short- and medium-term follow-up and allows a return to practicing sports in most cases. Patients with preoperative OA ≥ 2 seem to experience insufficient gains from MO surgery, so surgeons should be reluctant to apply the technique under these circumstances.

Does treatment by a specialist physiotherapist change pain and function in young adults with symptoms from femoroacetabular impingement? A pilot project for a randomised controlled trial.

AIM: Femoroacetabular impingement (FAI) is recognised as a source of hip pain but the effect of conservative treatment remains untested. This pilot study aimed to inform and evaluate the methods required to conduct a substantive trial comparing the effect of treatment by a physiotherapist versus routine care on the symptoms of FAI. DESIGN: A parallel group, pilot randomised controlled trial (RCT). SETTING: A single NHS acute hospital trust, Devon, England. PARTICIPANTS: 30 adults with symptomatic FAI were recruited. 23 (77%) completed the study. INTERVENTIONS: Intervention was 3 months of treatment by a specialist physiotherapist. The control group received routine care. MAIN OUTCOMES: Change in pain and function was measured using a Visual Analogue Scale, Non Arthritic Hip Score (NAHS), Lower Extremity Functional Score (LEFS) and Hip Outcome Score. RESULTS: Participants in the intervention arm undertook a personalised exercise programme to improve pelvic and femoral control plus advice on posture, activity pacing and pain relief. The mean change in NAHS for the intervention group was 12.7 (95% CI 4.7 to 20.7) and 1.8 (95% CI -5.3 to 9.0) in the control group; Median change in LEFS was 11.5 (95% CI 5.0 to 26.0) versus -1.0 (95% CI -7.0 to 4.0). This improvement in LEFS was beyond minimal clinically important difference in the intervention group. Pain scores improved marginally in both groups. CONCLUSIONS: Methodological strengths and weaknesses were successfully identified for a substantive study. Further research is needed to evaluate the relative influence of structural and neuromuscular features on symptoms of FAI and the role of conservative treatment.

A multi-centre randomized controlled trial comparing arthroscopic osteochondroplasty and lavage with arthroscopic lavage alone on patient important outcomes and quality of life in the treatment of young adult (18-50) femoroacetabular impingement.

BACKGROUND: Several cross-sectional studies have estimated that the prevalence of femoroacetabular impingement (FAI) ranges from 14-17% among asymptomatic young adults to almost 95% among competitive athletes. With FAI, there is abnormal contact between the proximal femur and the acetabulum, resulting in abnormal mechanics with terminal motion such as hip flexion and rotation. This condition results from bony anomalies of the acetabular rim (Pincer) and or femoral head/neck junction (CAM) and typically causes hip pain and decreased hip function. The development of hip pain potentially serves as an indicator for early cartilage and labral damage that may result in hip osteoarthritis. Although surgical correction of the misshaped bony anatomy and associated intra-articular soft tissue damage of the hip is thought to improve hip pain and alter the natural history of degenerative disease, the supportive evidence is based upon low quality observational studies. The Femoroacetabular Impingement RandomiSed controlled Trial (FIRST) compares outcomes following surgical correction of the impingement morphology (arthroscopic osteochondroplasty) with/without labral repair versus arthroscopic lavage of the hip joint in adults aged 18 to 50 diagnosed with FAI. METHODS AND DESIGN: FIRST is a multi-centre, randomized controlled trial with a sample size of 220 patients. Exclusion criteria include the presence of hip syndromes, previous surgery or trauma to the affected hip, and significant medical comorbidities. The primary outcome is pain and the secondary outcomes include patient function, quality of life, complications, and cost-effectiveness--all within one year of follow-up. Patients are stratified based on centre and impingement sub-type. Patients, outcome assessors, data analysts, and the Steering Committee are blinded to surgical allocation. Using an intention-to-treat approach, outcome analyses will be performed using an analysis of covariance and descriptive statistics. DISCUSSION: Symptomatic FAI is associated with chronic hip pain, functional limitations, and secondary osteoarthritis. Therefore, optimizing treatment has the potential to improve the lives millions of young, active persons who are diagnosed with this condition. Few orthopaedic surgical trials have similar potential to shift the paradigm of care dramatically towards (or away) from surgical bony and soft tissue interventions. TRIAL REGISTRATION: The FIRST trial is registered with clinicaltrials.gov (NCT01623843).

Vulvodynia and Concomitant Femoro-Acetabular Impingement: Long-Term Follow-up After Hip Arthroscopy.

OBJECTIVE: We hypothesized that in patients with vulvodynia and femoro-acetabular impingement (FAI), vulvar pain may be generated by the effect of FAI on pelvic floor structures, and treatment with arthroscopy may improve vulvodynia. We also sought to identify characteristics of patients whose vulvodynia improved after arthroscopy. MATERIALS AND METHODS: A case series of patients with vulvodynia and FAI underwent physical therapy, and, if hip symptoms did not improve, arthroscopy. Three to 5 years postoperatively, follow-up of outcomes after arthroscopy on vulvodynia was performed using chart review and patient questionnaire. Clinical characteristics and pain scores describing patients with and without vulvodynia improvement were assessed. RESULTS: Twenty-six patients with generalized unprovoked vulvodynia (GUV) or clitorodynia underwent arthroscopy for FAI. Six patients, all younger than 30 years, experienced lasting improvement in vulvodynia. Twenty patients, with an older mean age, longer mean vulvodynia duration, and mainly severe pain scores, did not experience vulvar pain improvement after arthroscopy. CONCLUSION: This case series describes improved vulvodynia outcomes after arthroscopy for FAI in women younger than 30 years. Patients with vulvar pain and coexisting FAI had GUV and clitorodynia.

Psychologic distress reduces preoperative self-assessment scores in femoroacetabular impingement patients.

BACKGROUND: In several areas of orthopaedics, including spine and upper extremity surgery, patients with greater levels of psychologic distress report worse self-assessments of pain and function than patients who are not distressed. This effect can lead to lower than expected baseline scores on common patient-reported outcome scales, even those not traditionally considered to have a psychologic component. QUESTIONS/PURPOSES: The purposes of this study were to determine (1) the association of psychologic distress and baseline modified Harris hip scores and Hip Outcome Scores in patients undergoing hip arthroscopy; and (2) whether psychologic distress would remain a significant negative predictor of baseline hip scores when other clinical variables such as age, sex, BMI, smoking status, and American Society of Anesthesiologists (ASA) classification were controlled. METHODS: One hundred forty-seven patients at one center were prospectively enrolled when they scheduled hip arthroscopy to treat painful femoroacetabular impingement. Before surgery, psychologic distress was quantified using the Distress Risk Assessment Method questionnaire. Patients also completed baseline self-assessments of hip pain and function including the modified Harris hip score and the Hip Outcome Score. Age, sex, BMI, smoking status, and ASA classification were recorded for each patient. Bivariate correlations and multivariate regression models were used to assess the effect of psychologic distress on patient self-assessment of hip pain and function. RESULTS: Patients with distress reported significantly lower baseline modified Harris hip scores (58 versus 67, p = 0.001), Hip Outcome Score-Activities of Daily Living scores (62 versus 72, p = 0.002), and Hip Outcome Score-Sports scores (36 versus 47, p = 0.02). Distress remained significantly associated with lower baseline modified Harris hip (p = 0.006), Hip Outcome Score-Activities of Daily Living (p = 0.005), and Hip Outcome Score-Sports scores (p = 0.017) when age, sex, BMI, smoking status, and ASA classification were controlled for in the multivariate model. CONCLUSIONS: Practitioners should recognize that psychologic distress has a negative correlation with baseline patient self-assessment using the modified Harris hip score and the Hip Outcome Scores, scales not previously described to correlate with psychologic distress. Longitudinal followup is warranted to clarify the relationship between distress and self-perceived disability and the effect of distress on postoperative outcomes in patients having hip arthroscopy. LEVEL OF EVIDENCE: Level III, prognostic study. See the Instructions for Authors for a complete description of levels of evidence.

Results of treatment of femoroacetabular impingement in adolescents with a surgical hip dislocation approach.

BACKGROUND: The literature contains few studies of open treatment with an open surgical hip dislocation approach for treatment of femoroacetabular impingement (FAI) in adolescents. The average age and associated disorders in adolescents with FAI reveal a critical need to study younger patients whose hip disorder has not had time to progress. QUESTIONS: We assessed (1) how validated measures of patient-oriented assessment of hip function and quality of life change after surgical hip dislocation; (2) whether any patient-related or technique variables correlated with changes in the outcome scores; and (3) what the complications of treatment are and how many reoperations we performed on these patients. METHODS: We retrospectively reviewed a consecutive series of 71 hips in adolescents younger than 21 years who underwent surgical hip dislocation for FAI. The final cohort consisted of 44 patients (52 hips) with a mean age of 16 years. We analyzed changes in outcome variables after surgical hip dislocation and recorded reoperations during the study period. RESULTS: The minimum followup was 12 months (average, 27 months; range, 12-60 months). Modified Harris hip scores increased from a mean of 57.7 preoperatively to a mean of 85.8 postoperatively. Mean SF-12 scores increased from 42.3 to 50.6. Mean preoperative hip flexion increased from 97.5° to 106.2°. Mean internal rotation of the affected hip at 90° flexion increased from 18.19° to 34°. CONCLUSIONS: Early results revealed improvements in hip function, patient quality of life, and ROM after surgical hip dislocation for the majority of this group of adolescents with FAI. However, 10% of the patients did not improve, and an additional 15% improved but still did not consider their hips good or excellent. This points toward the need for further studies in this population of patients.