Systematic Review
Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review Vandit Sardana, M.Sc., M.D., Marc J. Philippon, M.D., Darren de Sa, M.D., Asheesh Bedi, M.D., Lily Ye, B.Sc.Cand., Nicole Simunovic, M.Sc., and Olufemi R. Ayeni, M.Sc., M.D., F.R.C.S.C.
Purpose: To identify the indications and outcomes in patients undergoing revision hip arthroscopy. Methods: The electronic databases Embase, Medline, HealthStar, and PubMed were searched from 1946 to July 19, 2014. Two blinded reviewers searched, screened, and evaluated the data quality of the studies using the Methodological Index for NonRandomized Studies scale. Data were abstracted in duplicate. Agreement and descriptive statistics are presented. Results: Six studies were included (3 prospective case series and 3 retrospective chart reviews), with a total of 448 hips examined. The most common indications for revision hip arthroscopy included residual femoroacetabular impingement (FAI), labral tears, and chondral lesions. The mean interval between revision arthroscopy and the index procedure was 25.6 months. Overall, the modified Harris Hip Score improved by a mean of 33.6% (19.3 points) from the baseline score at 1year follow-up. In 14.6% of patients, further surgical procedures were required, including re-revision hip arthroscopy (8.0%), total hip replacement (5.6%), and hip resurfacing (1.0%). Female patients more commonly underwent revision hip arthroscopy (59.7%). Conclusions: The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (modified Harris Hip Score) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame. Level of Evidence: Level IV, systematic review of Level III and IV studies.
W
ithin the past decade, hip arthroscopy has become an increasingly common technique to address conditions such as femoroacetabular impingement (FAI), acetabular labral tears, chondral defects, hip capsular laxity/instability, ligamentum teres defects, coxa saltans, adhesive capsulitis, and extraarticular injuries.1-9 The favorable short-term clinical From the Division of Orthopaedic Surgery, Department of Surgery (V.S., D.d.S., O.R.A.), Department of Life Science (L.Y.), and Department of Clinical Epidemiology and Biostatistics (N.S.), McMaster University, Hamilton, Ontario, Canada; Steadman Philippon Research Institute (M.J.P.), Vail, Colorado; and MedSport at Domino’s Farms (A.B.), Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: M.J.P. receives support from Smith & Nephew, MIS, Ossur, Siemens, Arthrosurface, DonJoy, Slack, Linvatec, and HIPCO. A.B. receives support from Smith & Nephew and A3 Surgical. O.R.A. receives support from Smith & Nephew. Received December 12, 2014; accepted March 23, 2015. Address correspondence to Olufemi R. Ayeni, M.Sc., M.D., F.R.C.S.C., McMaster University Medical Center, Room 4E15, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/141048/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.03.039
outcomes of hip arthroscopy have been reported in the literature, with several case series indicating good to excellent short- and intermediate-term clinical outcomes10-17 and low rates of complications. Nevertheless, treatment failures do occur in patients after surgery. Some patients continue to present with pain and poor functional outcomes and may be candidates for a revision procedure in the setting of recurrent or missed structural pathology.18 Knowledge of unsatisfactory outcomes, particularly the need for revision hip arthroscopy, would help enhance our understanding of the predictors of outcomes for both surgeons and patients. This systematic review aims to provide clinicians with a comprehensive survey of current indications for and outcomes of revision hip arthroscopy.
Methods Search Strategy Two blinded reviewers (V.S., L.Y.) independently searched the online databases Embase, Medline,
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HealthStar, and PubMed from 1946 to July 19, 2014, for literature addressing revision hip arthroscopy. The research question and inclusion and exclusion criteria were determined a priori. The key terms “hip,” “hip joint,” “arthroscopy,” “hip preservation surgery,” “revision,” “postoperative complications,” and “reoperation” were used. The titles, abstracts, and full text were screened in duplicate. Discussion between the 2 reviewers took place to address any disagreements, and if needed, the senior author (O.R.A.) resolved study selection. Studies were included if they included (1) hip arthroscopic procedures, (2) revision surgical procedures, and (3) human subjects (i.e., no cadaveric studies). Studies were excluded if they (1) reported no surgical outcomes, such as radiographic studies, review articles, and instructional course lectures, and (2) did not evaluate hip/acetabular pathology. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to perform a quality assessment of the included studies.19 The MINORS scale is a 12-item, validated scoring tool for non-randomized studies.19 The items can be given a score from 0 to 2, with an ideal score for noncomparative studies being 16 and an ideal score for comparative studies being 24.19 Data Abstraction Two reviewers (V.S., L.Y.) abstracted data in duplicate and kept the records in a Microsoft Excel 2007 spreadsheet (Microsoft, Redmond, WA). The data included year of publication, author, location of study, study design, patient demographic data (age, sample size, number of male and female patients, right or left hip, and so on), type of surgery, mean interval between index and revision surgery, and type of procedure performed during index surgery and during revision surgery, as well as length of follow-up and patient-reported outcome measures. Statistical Analysis For all stages of the abstract and full-text screening, a weighted k was calculated to assess inter-rater agreement.20 An intraclass correlation coefficient was used to evaluate the quality-assessment score (MINORS) agreement.20 Reviewers erred on the side of study inclusion; therefore, at the title screening stage, a study was included if at least 1 reviewer maintained that the study should be included. The following interpretation of the k values was selected a priori: a k value of 0.61 or greater indicates substantial agreement; k of 0.21 to 0.60, moderate agreement; and k of 0.20 or lower, slight agreement.20 Descriptive statistics for the included studies were presented. A meta-analysis was not feasible because there were no intra-study comparison data and the 6 studies showed variability regarding study design, surgical technique, and
patient-reported outcome measures. A formal assessment of heterogeneity was therefore not feasible.
Results Study Identification Of the initial 842 studies found, 8 proceeded to fulltext screening. One study was excluded for being a review article,18 and one study was excluded for reporting results of the same patient group included in a later study.21 Ultimately, 6 studies were included in this review (Fig 1). Screening of the reference sections of these 6 studies did not yield any additional results. Of the 6 studies, 5 were full-text articles.22-26 One study was presented in abstract form at a conference and was not peer reviewed but reported relevant data.27 Detailed results of the included studies are shown in Tables 1 and 2. The reviewers showed substantial agreement in selecting articles for inclusion at the abstract stage, with k ¼ 0.99 (1 of 842 articles in disagreement), and at the full-text screening stage, with k ¼ 1.0. A third reviewer was not required to resolve discrepancies. Study Characteristics There were 3 prospective case series24,26,27 and 3 retrospective chart reviews.22,23,25 The included studies had a mean MINORS score of 9.7 of 16 (Table 1). There was also high agreement among quality-assessment scores of included studies using the MINORS criteria, with an intraclass correlation coefficient of 0.95 (95% confidence interval, 0.88 to 0.96). All studies were conducted in the United States, and sample sizes ranged from 24 to 192 subjects, with 50% of the studies (3 of 6) examining at least 50 patients. Five studies were Level IV evidence and one was Level III evidence. A total of 448 hips were evaluated. Study Findings The mean interval between the index procedure and revision surgery was 25.6 months. The mean patient age was 33.4 years, and 59.7% of total patients were female patients. The patient demographic data were similar in all 6 studies, as detailed in Table 1. Most of the studies reviewed indicated incomplete FAI treatment as the leading cause of revision surgery.22,25,27 FAI was treated in 37.9% of the index operations and 63.6% (range, 32% to 95%) of the revision operations (Fig 2). The studies in this review found that complete resection of cam pathology and complete resection of focal rim pathology,22-27 as assessed by postoperative radiographs, were positive predictive factors for improved functional outcomes after revision hip arthroscopy. Among the FAI cases, cam lesions were addressed by 29.8% of index operations and 37.2% of revision
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REVISION HIP ARTHROSCOPY
Fig 1. Outline of search strategy.
operations. Pincer lesions were addressed by 8.1% of index operations and 26.4% of revision operations (Fig 3). Labral repair or debridement was performed in 72.6% of index operations and 77.9% of revision operations (Fig 2). There were other procedures reported including cam and/or rim osteoplasty, chondroplasty, microfracture, psoas release, trochanteric bursectomy, loose body removal, capsular plication, thermal capsulorrhaphy, ligamentum teres debridement, and adhesiolysis in conjunction with FAI surgery. A detailed chart of various procedures performed during index surgery and revision surgery with weighted means is shown in Table 3. After initial revision hip arthroscopy, 14.6% of patients (reported in 4 of 6 studies) did not achieve satisfactory clinical improvement and pursued additional interventions, such as re-revision hip arthroscopy (8%), total hip replacement (5.6%), or hip resurfacing (1%). All studies examined in this review reported successful short- and intermediate-term outcomes with
revision hip arthroscopy.22-27 Although other outcome measures were used in some of the studies,24,25 they were not used consistently across all studies and, therefore, would not allow for any comprehensive comparisons. The outcome measure used across 50% of the studies was the modified Harris Hip Score (mHHS). Overall, the mHHS improved by a mean of 33.6% (19.3 points) from the baseline score at 1-year follow-up.
Discussion Key Findings This systematic review examined the indications for and outcomes of revision hip arthroscopy and reported favorable overall improvement in patient outcomes by a mean of 33.6% (19.3 points) on the mHHS, although 14.6% of patients underwent additional procedures for residual symptoms after a mean follow-up of 21 months.22-27 The results of this review show (1) short- to medium-term (12 to 36 months) improvement in patient outcomes (mHHS), with 33.6%
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Preoperative 62.1 NR 53.8 56 NR 55 57.4 Study Larson et al.25 Gwathemy et al.27 Aprato et al.26 Philippon et al.22 Heyworth et al.23 Domb et al.24 Mean
T Re Pr Pr Re Re Pr NA
L III IV IV IV IV IV NA
Year 2014 2014 2014 2007 2007 2014 NA
SS 85 192 63 37 24 47 448
MS 8 of 16 12 of 16 11 of 16 9 of 16 7 of 16 11 of 16 9.7
MA, yr 29.5 33 37 33 33.6 37.1 33.4
Female 44 116 36 25 14 26 261
Male 35 72 27 12 9 21 176
MFU, mo 26 12 36 12 NR 36 21
MIBR, mo NR 24 36 20.5 25.6 22 25.6 Gender
Table 1. Study Characteristics
L, level of evidence; MA, mean age; MFU, mean follow-up; mHHS, modified Harris Hip Score; MIBR, mean interval between index and revision surgery; MS, Methodological Index for NonRandomized Studies score; NA, not applicable; NR, not reported; Pr, prospective; Re, retrospective; SS, sample size; T, type of study.
mHHS
Change at 6 wk NR NR 0.33 NR NR 10 4.1
Change at 6 mo NR NR 7.8 NR NR NR 7.8
Change at 1 yr NR 22 9.7 21 NR 20 19.3
Change at 2 yr 17.8 NR 10.7 NR NR 15 14.8
Change at 3 yr NR NR 4.4 NR NR 17 9.8
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improvement from baseline at 1 year after revision hip arthroscopy; (2) unaddressed or inadequately addressed FAI at index surgery as the most common indication for revision hip arthroscopy; (3) labral tears and chondral defects as other common concomitant indications for revision hip arthroscopy; and (4) associative findings of female predominance for revision hip arthroscopy (59.7%). Harris et al.,28 in their meta-analysis of 6,334 hips, reported that the reoperation rate after index hip arthroscopy was 6.8%, with 2.9% converting to total hip arthroplasty, whereas with revision hip arthroscopy, the reoperation rate was 14.6%, with 5.9% converting to total hip arthroplasty. In 2009 Philippon et al.29 reported outcomes of primary hip arthroscopy for FAI, with a mean improvement in the mHHS by 24 points. Nho and colleagues30 reported that the minimal clinically important difference for the mHHS in hip arthroscopy is 20.0 points at 1 year. Revision hip arthroscopy shows an improvement in the mHHS by 19.3 points at the 1-year mark, which is consistent with outcomes of primary hip arthroscopy and makes a clinically important difference. Thus revision hip arthroscopy does improve patient-reported outcomes to make a clinical difference but is not as successful as index hip arthroscopy in terms of the reoperation rate. The studies included in this review did not detail the cause of the higher reoperation rate. There could be various reasons for reoperation such as infection, prolonged rehabilitation, inadequate resection of FAI, and further labral tears and chondral damage because of the prolonged time between the initial presentation and treatment because the index operation was unable to adequately treat FAI. Interesting Findings The mean interval between index and revision hip arthroscopy was 25.6 months (range, 20.5 to 36 months), which may represent the approximate length of time it took for patients to be affected by their symptoms or function, consult a surgeon, obtain an investigation of the potential issues at hand, agree to the revision procedure, and undergo the revision procedure. Harris et al.28 reported a mean period of 16.4 months between index hip arthroscopy and reoperation. Therefore surgeons should consider incorporating a minimum 2-year follow-up after index hip arthroscopy. These data on timing should be considered with caution because the included studies rarely detailed the length of time from clinical presentation to the actual time of revision surgery. The studies showed that the patients who most commonly require a revision are female patients (59.7%) and young patients, with a mean age of 33.4 years. Laborie et al.31 and Hetsroni et al.32 have previously reported cam radiographic findings of FAI to
REVISION HIP ARTHROSCOPY
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Table 2. Results and Conclusions of Included Studies Author Larson et al.25
Gwathemy et al.27
Aprato et al.26
Philippon et al.22
Heyworth et al.23
Domb et al.24
Result The authors reported improved outcomes after arthroscopic hip revision surgery for residual FAI. These were found to be inferior to the index surgery. They compared revision surgery with index surgery for FAI, but they only included data for patients undergoing revision surgery for FAI. A total of 79 patients with a mean age of 29.5 years were reported. The labrum was debrided in 32% of hips, repaired in 57% of hips, and reconstructed in 9% of hips. More than 70% of their cases showed a chondral defect and/or recurrent or new labral disease that required treatment at the time of revision surgery. Residual cam-type deformity was often found. They reported improvements for FAI revision by 17.8 points (mHHS), 12.5 points (SF-12), and 1.4 points (VAS) compared with 23.4 points (mHHS), 19.7 points (SF-12), and 4.6 points (VAS) after index arthroscopic FAI correction. The authors presented an abstract at the 2014 meeting of the Arthroscopy Association of North America. Index FAI correction had been performed in 24.5% of patients, with an improvement of 25 points on the mHHS. Revisions focused on correcting FAI in 17% of patients, with an improvement of 19 points on the mHHS. In 21.3% of patients, previous correction of FAI had been performed and no further correction was needed, improving by 18 points on the mHHS. In 37.5% of patients, there was no FAI and no correction was needed, and the mHHS improved by 26 points. The mean preoperative mHHS for 63 patients was 54 points. The mean postoperative mHHS was 53 points at 6 weeks, 62 points at 6 months, 63 points at 1 year, 64 points at 2 years, and 59 points at 3 years.
The common clinical findings in patients requiring revision surgery were hip pain, decreased range of motion, and functional disability. Revision procedures were performed because of FAI (95%), labral lesions (87%), chondral defects (70%), adhesiolysis (62%), and previously unaddressed instability (35%). The mean time from index surgery to revision surgery was 20.5 months. Further procedures were needed after revision surgery in 13.5% of patients. They had a mean follow-up of 12.7 months. The mean interval between index surgery and symptoms was 6.1 months. Eight cases had a failed labral repair, which was addressed with labral debridement and removal of suture material. Of these 8 cases, 6 had bony impingement that was also addressed at the time of revision surgery. The authors reported the results of a 2-year follow-up of 47 revisions by hip arthroscopy. In 66% of hips, FAI that was unaddressed or inadequately addressed was present at the time of revision. The authors reported significant improvements in all patient-reported outcome scores at a mean of 29 months after revision. They also found improvement in the Non-Arthritic Hip Score by at least 10 points in 65% of hips and 20 points in 44% of hips.
Conclusion Greater postoperative head-neck offset, subspine/ AIIS decompression, labral repair/reconstruction, and capsular placation were significant predictors of better outcomes after index surgery.
The authors concluded that, overall, there was a 22-point improvement in the mHHS at a minimum follow-up of 12 months, with 87% of patients showing improvements in measurable outcomes.
The authors found acetabular chondral lesions to be the major cause of revision hip arthroscopy. Of their patients, 31% underwent revision because of persistent FAI, and this cohort of patients did not do well regarding patientreported outcome scores at the 3-year mark. FAI was the major cause of revision hip arthroscopy. The authors also suggested the need for labral lesions and other soft-tissue abnormalities to be addressed because they are essential to the longterm success of the treatment of bony abnormalities.
The authors concluded that failure to address bony impingement and soft-tissue defects, such as a tight psoas tendon, are the major reasons for revision hip arthroscopy. They also concluded that failure of labral repairs in index surgery could be a result of unrecognized bony impingement. The authors concluded that pincer impingement, cam impingement, symptomatic heterotopic ossification, previous open surgery, and segmented labral defects treated with labral reconstruction were positive predictive factors for improved functional outcomes after revision hip arthroscopy. FAI was reported as a significant factor for the failure of hip arthroscopy.
AIIS, anterior inferior iliac spine; FAI, femoroacetabular impingement; mHHS, modified Harris Hip Score; SF-12, Short Form 12; VAS, visual analog scale.
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abnormalities. The reason for the increased revision of acetabular-sided lesions and in female patients is unknown and prompts further investigation.
Fig 2. Comparison of procedures performed during index versus revision hip arthroscopy: chondroplasty (C), microfracture (M), labrectomy (LT), labral repair (LR), femoroacetabular impingement correction (FAI), psoas release (P), trochanteric bursectomy (TB), loose body removal (LBR), capsular plication (CP), thermal capsulorrhaphy (TC), ligamentum teres debridement (LTD), and adhesiolysis (A).
be common in healthy young male patients. In addition, women are known to have a higher prevalence of pincer-type deformities.33 The percentage of acetabulum-based corrections performed during the revision operations (26.9%) was higher than the reported prevalence during index hip arthroscopy (11% according to Harris et al.28). Nepple et al.34 recently reported that female patients tend to have higher symptomatology with milder morphologic
Fig 3. Breakdown of femoroacetabular impingement into cam and pincer impingement for comparison of index versus revision hip arthroscopy.
Femoroacetabular Impingement The studies that did not subspecify FAI explicitly into cam- and pincer-type deformity may have represented mixed pathology and, when combined, resulted in FAI as the greatest cause of revision (64.3%). FAI correction was performed in 37.9% of index procedures, which is consistent with the literature.28 The results suggest that pincer-type lesions were addressed 3 times more frequently at revision hip arthroscopy (26.4%) when compared with index hip arthroscopy (8.1%). Nevertheless, cam-type impingement (37.2%), either unaddressed or inadequately addressed, was more commonly the cause for revision when compared with pincer-type impingement (26.4%). It is crucial to note that revision surgery in which a labral tear was the sole issue addressed was a rare finding, with most of the revision operations being combined with surgical management of FAI or chondral defects. This review showed that there was not a difference in the number of index operations versus revision operations performed for isolated labral pathology. In contrast, the percentage of FAI lesions treated during revision surgery nearly doubled when compared with index surgery. In 2001 McCarthy et al.35 concluded that labral injury through impingement at the extremes of motion leads to a series of progressive events including labral fraying, tearing, cartilage delamination, and finally, labral and cartilage degeneration. Consequently, incomplete FAI treatment during index surgery may result in further cartilage and labral pathology being seen and treated during revision hip arthroscopy. FAI pathology being treated during revision arthroscopy may be the result of recurrence or inadequate treatment during index surgery. None of the studies included in the review detailed the alpha angle correction during the index operation to determine if the alpha angle seen before revision hip arthroscopy changed in the period between index and revision surgery or was not adequately addressed at the time of index surgery. The osseous bump regrowth rate is believed to be 16% despite adequate resection, although Gupta et al.36 have recently shown that cam lesions after adequate osteoplasty do not tend to regrow when followed for a period of 2 years.37 Zaltz et al.38 have concluded that certain acetabular and extra-articular pathomorphologic entities are better treated with an open approach than with an arthroscopic approach. In addition, Bedi et al.39 have evaluated the efficacy of arthroscopic and open surgery regarding alpha angles and concluded that symptomatic posterolateral cam morphology can be effectively treated with an open approach. Furthermore, Matsuda
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REVISION HIP ARTHROSCOPY Table 3. Procedures Performed During Index and Revision Hip Arthroscopy With Weighted Means
Index hip arthroscopy Chondroplasty Microfracture Partial labrectomy Labral suture Cam excision Pincer excision Psoas release Trochanteric bursectomy Loose body removal Capsular plication Thermal capsulorrhaphy Ligamentum teres debridement Adhesiolysis Revision hip arthroscopy Chondroplasty Microfracture Partial labrectomy Labral suture Cam excision Pincer excision Psoas release Trochanteric bursectomy Loose body removal Capsular plication Thermal capsulorrhaphy Ligamentum teres debridement Adhesiolysis
Larson et al.25
Gwathemy et al.27
Aprato et al.26
Philippon et al.22
Heyworth et al.23
Domb et al.24
Mean
Sample Size
NR NR NR NR NR NR NR NR NR NR NR NR NR
NR NR NR NR NR NR NR NR NR NR NR NR NR
34 3 30 4 20 3 4 0 NR NR NR NR 0
17 9 25 7 10 5 NR NR 6 6 4 6 NR
NR NR 16 8 7 2 1 NR NR 1 1 4 NR
NR NR NR NR NR NR NR NR NR NR NR NR NR
51.0% 12.0% 57.3% 15.3% 29.8% 8.1% 5.7% 0.0% 16.2% 11.5% 8.2% 16.4% 0.0%
100 100 124 124 124 124 87 63 37 61 61 61 63
NR 7 83 NR NR NR NR NR NR 23 NR 80 54
88 14 80 NR 66 32 17 NR 17 NR NR 34 56
19 10 15 10 12 8 9 6 NR NR NR NR 7
28 18 23 9 28 17 NR NR 10 10 3 21 15
NR NR 19 2 8 14 7 2 7 1 1 NR NR
20 4 27 18 21 25 17 NR 12 14 NR 7 NR
45.7% 12.5% 55.1% 22.8% 37.2% 26.4% 15.3% 9.2% 15.3% 24.9% 6.6% 39.3% 35.0%
339 424 448 171 363 363 326 87 300 193 61 361 377
NR, not reported.
et al.40 recently have shown that cam impingement extends beyond the described anterolateral quadrant of the proximal femur to the anteromedial corner. Pincer deformities occur in focal and global forms. Usually, global overcoverage of the acetabulum is challenging and is better treated with open surgical dislocation. Matsuda et al.41 have described dual-portal hip arthroscopy with central-compartment access, subtotal acetabuloplasty, and circumferential chondrolabral surgery. The size and location of the cam and pincer lesions being treated in the studies evaluated have not been reported in substantial detail. As such, it is unknown if the pathology being treated would be less challenging and more comprehensively addressed with an open approach to index surgery. Limitations This systematic review highlights the need for further investigation addressing this topic. Prospective randomized trials with a large number of participants and long-term follow-up would be ideal but might not be feasible because of the resource-intensive nature and methodologic challenges of such surgical trials.42 Further prospective cohort studies may be more feasible and less costly and will be able to compare the outcomes and failure rates with a group of patients who underwent index arthroscopic surgery.
There is a steep learning curve associated with FAI correctional surgery.43 The data in the studies included in this review are from centers where there is noted expertise and a high volume of hip arthroscopy procedures. Thus the reported results may not be generalizable to surgeons in lower-volume centers or with lesser expertise. Because there have also been significant advances in imaging and postoperative rehabilitation, further studies should be conducted incorporating how these factors affect the outcomes of revision hip arthroscopy. It would be ideal to compare what exact diagnostic modalities, such as intra-articular injections, clinical examination findings, and imaging findings, were used in decision making before index and revision hip arthroscopy. Aprato et al.44 and Claßen et al.45 have independently shown poor outcomes if the FAI or chondral lesions are not treated within the first 6 months of the onset of symptoms. None of the studies in this review reported the timing of index surgery with respect to the initial onset of symptoms. This may have contributed to selection bias. Because our understanding of the biomechanics of the hip joint is improving, various extracapsular entities, such as subspine impingement and psoas impingement,46 ischiofemoral impingement, and greater trochanteric/pelvic impingement, will be
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considered. These entities are challenging to diagnose with current radiologic techniques and are usually diagnosed intraoperatively.38,47,48 It is possible that better recognition of these entities will allow for identification of causes of failure that were previously unknown. All of the studies evaluated used magnetic resonance imaging/MRI arthrogram and plain radiographs to diagnose the etiology of failure preoperatively but did not detail if any of the aforementioned entities were considered. In summary, the limitations of this review include low-quality evidence, inconsistent reporting, possible expertise bias, and unclear diagnosis information. The studies were either Level III or IV evidence, and 5 studies lacked a reported control group. Follow-up times were variable, and sample sizes were generally small. The studies were inconsistent regarding imaging modalities used and patient-reported outcomes. Hetaimish et al.49 have previously highlighted inconsistency of reported outcomes after FAI surgery and a need for consistency in reporting outcomes to compare studies. Most of the data findings in this review are therefore associative, not causative. Furthermore, many of the authors were also the primary surgeons and had noted expertise in hip arthroscopy, leading to possible expertise and selection bias in reporting of the study results. Finally, the pathology being treated was selected by the surgeon on the basis of radiographic findings but was not explicitly detailed to be the cause of pain.
Conclusions The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (mHHS) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame.
References 1. Byrd JW, Jones KS. Adhesive capsulitis of the hip. Arthroscopy 2006;22:89-94. 2. McCarthy JC, Lee J. Hip arthroscopy: Indications and technical pearls. Clin Orthop Relat Res 2005;441:180-187. 3. McCarthy JC, Lee JA. Arthroscopic intervention in early hip disease. Clin Orthop Relat Res 2004;429:157-162.
4. Shindle MK, Ranawat AS, Kelly BT. Diagnosis and management of traumatic and atraumatic hip instability in the athletic patient. Clin Sports Med 2006;25:309-326. ix-x. 5. Kelly BT, Williams RJ III, Philippon MJ. Hip arthroscopy: Current indications, treatment options, and management issues. Am J Sports Med 2003;31:1020-1037. 6. Kelly BT, Weiland DE, Schenker ML, Philippon MJ. Arthroscopic labral repair in the hip: Surgical technique and review of the literature. Arthroscopy 2005;21:1496-1504. 7. Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: Arthroscopic procedures and postoperative rehabilitation. J Orthop Sports Phys Ther 2006;36:516-525. 8. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA. Femoroacetabular impingement: A cause for osteoarthritis of the hip. Clin Orthop Relat Res 2003;417: 112-120. 9. Wenger DE, Kendell KR, Miner MR, Trousdale RT. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop Relat Res 2004;426:145-150. 10. Byrd JW. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280. 11. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy 2000;16:578-587. 12. Farjo LA, Glick JM, Sampson TG. Hip arthroscopy for acetabular labral tears. Arthroscopy 1999;15:132-137. 13. O’Leary JA, Berend K, Vail TP. The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy 2001;17:181-188. 14. Potter BK, Freedman BA, Andersen RC, Bojescul JA, Kuklo TR, Murphy KP. Correlation of Short Form-36 and disability status with outcomes of arthroscopic acetabular labral debridement. Am J Sports Med 2005;33:864-870. 15. Santori N, Villar RN. Acetabular labral tears: Result of arthroscopic partial limbectomy. Arthroscopy 2000;16:11-15. 16. Sampson TG. Complications of hip arthroscopy. Clin Sports Med 2001;20:831-835. 17. Griffin DR, Villar RN. Complications of arthroscopy of the hip. J Bone Joint Surg Br 1999;81:604-606. 18. Ward JP, Rogers P, Youm T. Failed hip arthroscopy: Causes and treatment options. Orthopedics 2012;35:612-617. 19. Slim K, Nini E, Forestier D, Kwiatkowski F, Panis Y, Chipponi J. Methodological index for non-randomized studies (MINORS): Development and validation of a new instrument. ANZ J Surg 2003;73:712-716. 20. McGinn T, Wyer PC, Newman TB, et al. Tips for learners of evidence-based medicine: 3 measures of observer variability (kappa statistic). CMAJ 2004;171:1369-1373. 21. Larson CM, Giveans MR, Bedi A, Samuelson KM, Stone RM. Arthroscopic hip revision surgery for residual FAI: Surgical outcomes. Presented at the International Society for Hip Arthroscopy Annual Meeting, Boston, MA, 2012. 22. Philippon MJ, Schenker ML, Briggs KK, Kuppersmith DA, Maxwell RB, Stubbs AJ. Revision hip arthroscopy. Am J Sports Med 2007;35:1918-1921. 23. Heyworth BE, Shindle MK, Voos JE, Rudzki JR, Kelly BT. Radiologic and intraoperative findings in revision hip arthroscopy. Arthroscopy 2007;23:1295-1302. 24. Domb BG, Stake CE, Lindner D, El-Bitar Y, Jackson TJ. Revision hip preservation surgery with hip arthroscopy: Clinical outcomes. Arthroscopy 2014;30:581-587.
REVISION HIP ARTHROSCOPY 25. Larson CM, Giveans MR, Samuelson KM, Stone RM, Bedi A. Arthroscopic hip revision surgery for residual femoroacetabular impingement (FAI): Surgical outcomes compared with a matched cohort after primary arthroscopic FAI correction. Am J Sports Med 2014;42: 1785-1790. 26. Aprato A, Jayasekera N, Villar RN. Revision hip arthroscopic surgery: Outcome at three years. Knee Surg Sports Traumatol Arthrosc 2014;22:932-937. 27. Gwathemy FW, Byrd JW, Jones K. Revision hip arthroscopy: Findings and outcomes. Arthroscopy 2014;30:e23 (suppl). 28. Harris JD, McCormick FM, Abrams GD, et al. Complications and reoperations during and after hip arthroscopy: A systematic review of 92 studies and more than 6,000 patients. Arthroscopy 2013;29:589-595. 29. Philippon MJ, Briggs KK, Yen Y-M, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: Minimum two-year follow-up. J Bone Joint Surg Br 2009;91:16-23. 30. Chahal J, Van Thiel GS, Mather RC, Lee S, Salata MJ, Nho SJ. The minimal clinical important difference (MCID) and patient acceptable symptomatic state (PASS) for the modified Harris Hip Score and Hip Outcome Score among patients undergoing surgical treatment for femoroacetabular impingement. Orthop J Sports Med 2014;2:20. 31. Laborie LB, Lehmann TG, Engesaeter IO, Engesaeter LB, Rosendahl K. Is a positive femoroacetabular impingement test a common finding in healthy young adults? Clin Orthop Relat Res 2013;471:2267-2277. 32. Hetsroni I, Dela Torre K, Duke G, Lyman S, Kelly BT. Sex differences of hip morphology in young adults with hip pain and labral tears. Arthroscopy 2013;29:54-63. 33. Pfirrmann CW, Mengiardi B, Dora C, Kalberer F, Zanetti M, Hodler J. Cam and pincer femoroacetabular impingement: Characteristic MR arthrographic findings in 50 patients. Radiology 2006;240:778-785. 34. Nepple JJ, Riggs CN, Ross JR, Clohisy JC. Clinical presentation and disease characteristics of femoroacetabular impingement are sex-dependent. J Bone Joint Surg Am 2014;96:1683-1689. 35. McCarthy JC, Noble PC, Schuck MR, Wright J, Lee J. The watershed labral lesion: Its relationship to early arthritis of the hip. J Arthroplasty 2001;16:81-87 (suppl 1). 36. Gupta A, Redmond JM, Stake CE, Finch NA, Dunne KF, Domb BG. Does the femoral cam lesion regrow after osteoplasty for femoroacetabular impingement? Two-year follow-up. Am J Sports Med 2014;42:2149-2155.
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37. Sawalha S, Dixon S, Norton M, Fern E. Recurrence of femoral head-neck osseous ‘bumps’ after hip impingement surgery. J Bone Joint Surg Br 2011;93:48 (abstr, suppl I). 38. Zaltz I, Kelly BT, Larson CM, Leunig M, Bedi A. Surgical treatment of femoroacetabular impingement: What are the limits of hip arthroscopy? Arthroscopy 2014;30:99-110. 39. Bedi A, Zaltz I, De La Torre K, Kelly BT. Radiographic comparison of surgical hip dislocation and hip arthroscopy for treatment of cam deformity in femoroacetabular impingement. Am J Sports Med 2011;39:20S-28S (suppl). 40. Matsuda DK, Schnieder CP, Sehgal B. The critical corner of cam femoroacetabular impingement: Clinical support of an emerging concept. Arthroscopy 2014;30:575-580. 41. Matsuda DK, Gupta N, Hanami D. Hip arthroscopy for challenging deformities: Global pincer femoroacetabular impingement. Arthrosc Tech 2014;3:e197-e204. 42. Thoma A, Farrokhyar F, McKnight L, Bhandari M. Practical tips for surgical research: How to optimize patient recruitment. Can J Surg 2010;53:205-210. 43. Hoppe DJ, de Sa D, Simunovic N, et al. The learning curve for hip arthroscopy: A systematic review. Arthroscopy 2014;30:389-397. 44. Aprato A, Jayasekera N, Villar R. Timing in hip arthroscopy: Does surgical timing change clinical results? Int Orthop 2012;36:2231-2234. 45. Claßen T, Körsmeier K, Kamminga M, et al. Is early treatment of cam-type femoroacetabular impingement the key to avoiding associated full thickness isolated chondral defects? Knee Surg Sports Traumatol Arthrosc in press, available online 4 October, 2014. doi:10.1007/ s00167-014-3332-7. 46. de Sa D, Alradwan H, Cargnelli S, et al. Extra-articular hip impingement: A systematic review examining operative treatment of psoas, subspine, ischiofemoral, and greater trochanteric/pelvic impingement. Arthroscopy 2014;30: 1026-1041. 47. Larson CM, Kelly BT, Stone RM. Making a case for anterior inferior iliac spine/subspine hip impingement: Three representative case reports and proposed concept. Arthroscopy 2011;27:1732-1737. 48. Siebenrock KA, Steppacher SD, Haefeli PC, Schwab JM, Tannast M. Valgus hip with high antetorsion causes pain through posterior extraarticular FAI. Clin Orthop Relat Res 2013;471:3774-3780. 49. Hetaimish BM, Khan M, Crouch S, et al. Consistency of reported outcomes after arthroscopic management of femoroacetabular impingement. Arthroscopy 2013;29: 780-787.
Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review Vandit Sardana, M.Sc., M.D., Marc J. Philippon, M.D., Darren de Sa, M.D., Asheesh Bedi, M.D., Lily Ye, B.Sc.Cand., Nicole Simunovic, M.Sc., and Olufemi R. Ayeni, M.Sc., M.D., F.R.C.S.C.
Purpose: To identify the indications and outcomes in patients undergoing revision hip arthroscopy. Methods: The electronic databases Embase, Medline, HealthStar, and PubMed were searched from 1946 to July 19, 2014. Two blinded reviewers searched, screened, and evaluated the data quality of the studies using the Methodological Index for NonRandomized Studies scale. Data were abstracted in duplicate. Agreement and descriptive statistics are presented. Results: Six studies were included (3 prospective case series and 3 retrospective chart reviews), with a total of 448 hips examined. The most common indications for revision hip arthroscopy included residual femoroacetabular impingement (FAI), labral tears, and chondral lesions. The mean interval between revision arthroscopy and the index procedure was 25.6 months. Overall, the modified Harris Hip Score improved by a mean of 33.6% (19.3 points) from the baseline score at 1year follow-up. In 14.6% of patients, further surgical procedures were required, including re-revision hip arthroscopy (8.0%), total hip replacement (5.6%), and hip resurfacing (1.0%). Female patients more commonly underwent revision hip arthroscopy (59.7%). Conclusions: The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (modified Harris Hip Score) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame. Level of Evidence: Level IV, systematic review of Level III and IV studies.
W
ithin the past decade, hip arthroscopy has become an increasingly common technique to address conditions such as femoroacetabular impingement (FAI), acetabular labral tears, chondral defects, hip capsular laxity/instability, ligamentum teres defects, coxa saltans, adhesive capsulitis, and extraarticular injuries.1-9 The favorable short-term clinical From the Division of Orthopaedic Surgery, Department of Surgery (V.S., D.d.S., O.R.A.), Department of Life Science (L.Y.), and Department of Clinical Epidemiology and Biostatistics (N.S.), McMaster University, Hamilton, Ontario, Canada; Steadman Philippon Research Institute (M.J.P.), Vail, Colorado; and MedSport at Domino’s Farms (A.B.), Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: M.J.P. receives support from Smith & Nephew, MIS, Ossur, Siemens, Arthrosurface, DonJoy, Slack, Linvatec, and HIPCO. A.B. receives support from Smith & Nephew and A3 Surgical. O.R.A. receives support from Smith & Nephew. Received December 12, 2014; accepted March 23, 2015. Address correspondence to Olufemi R. Ayeni, M.Sc., M.D., F.R.C.S.C., McMaster University Medical Center, Room 4E15, 1200 Main St W, Hamilton, ON L8N 3Z5, Canada. E-mail: [email protected] Ó 2015 by the Arthroscopy Association of North America 0749-8063/141048/$36.00 http://dx.doi.org/10.1016/j.arthro.2015.03.039
outcomes of hip arthroscopy have been reported in the literature, with several case series indicating good to excellent short- and intermediate-term clinical outcomes10-17 and low rates of complications. Nevertheless, treatment failures do occur in patients after surgery. Some patients continue to present with pain and poor functional outcomes and may be candidates for a revision procedure in the setting of recurrent or missed structural pathology.18 Knowledge of unsatisfactory outcomes, particularly the need for revision hip arthroscopy, would help enhance our understanding of the predictors of outcomes for both surgeons and patients. This systematic review aims to provide clinicians with a comprehensive survey of current indications for and outcomes of revision hip arthroscopy.
Methods Search Strategy Two blinded reviewers (V.S., L.Y.) independently searched the online databases Embase, Medline,
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HealthStar, and PubMed from 1946 to July 19, 2014, for literature addressing revision hip arthroscopy. The research question and inclusion and exclusion criteria were determined a priori. The key terms “hip,” “hip joint,” “arthroscopy,” “hip preservation surgery,” “revision,” “postoperative complications,” and “reoperation” were used. The titles, abstracts, and full text were screened in duplicate. Discussion between the 2 reviewers took place to address any disagreements, and if needed, the senior author (O.R.A.) resolved study selection. Studies were included if they included (1) hip arthroscopic procedures, (2) revision surgical procedures, and (3) human subjects (i.e., no cadaveric studies). Studies were excluded if they (1) reported no surgical outcomes, such as radiographic studies, review articles, and instructional course lectures, and (2) did not evaluate hip/acetabular pathology. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to perform a quality assessment of the included studies.19 The MINORS scale is a 12-item, validated scoring tool for non-randomized studies.19 The items can be given a score from 0 to 2, with an ideal score for noncomparative studies being 16 and an ideal score for comparative studies being 24.19 Data Abstraction Two reviewers (V.S., L.Y.) abstracted data in duplicate and kept the records in a Microsoft Excel 2007 spreadsheet (Microsoft, Redmond, WA). The data included year of publication, author, location of study, study design, patient demographic data (age, sample size, number of male and female patients, right or left hip, and so on), type of surgery, mean interval between index and revision surgery, and type of procedure performed during index surgery and during revision surgery, as well as length of follow-up and patient-reported outcome measures. Statistical Analysis For all stages of the abstract and full-text screening, a weighted k was calculated to assess inter-rater agreement.20 An intraclass correlation coefficient was used to evaluate the quality-assessment score (MINORS) agreement.20 Reviewers erred on the side of study inclusion; therefore, at the title screening stage, a study was included if at least 1 reviewer maintained that the study should be included. The following interpretation of the k values was selected a priori: a k value of 0.61 or greater indicates substantial agreement; k of 0.21 to 0.60, moderate agreement; and k of 0.20 or lower, slight agreement.20 Descriptive statistics for the included studies were presented. A meta-analysis was not feasible because there were no intra-study comparison data and the 6 studies showed variability regarding study design, surgical technique, and
patient-reported outcome measures. A formal assessment of heterogeneity was therefore not feasible.
Results Study Identification Of the initial 842 studies found, 8 proceeded to fulltext screening. One study was excluded for being a review article,18 and one study was excluded for reporting results of the same patient group included in a later study.21 Ultimately, 6 studies were included in this review (Fig 1). Screening of the reference sections of these 6 studies did not yield any additional results. Of the 6 studies, 5 were full-text articles.22-26 One study was presented in abstract form at a conference and was not peer reviewed but reported relevant data.27 Detailed results of the included studies are shown in Tables 1 and 2. The reviewers showed substantial agreement in selecting articles for inclusion at the abstract stage, with k ¼ 0.99 (1 of 842 articles in disagreement), and at the full-text screening stage, with k ¼ 1.0. A third reviewer was not required to resolve discrepancies. Study Characteristics There were 3 prospective case series24,26,27 and 3 retrospective chart reviews.22,23,25 The included studies had a mean MINORS score of 9.7 of 16 (Table 1). There was also high agreement among quality-assessment scores of included studies using the MINORS criteria, with an intraclass correlation coefficient of 0.95 (95% confidence interval, 0.88 to 0.96). All studies were conducted in the United States, and sample sizes ranged from 24 to 192 subjects, with 50% of the studies (3 of 6) examining at least 50 patients. Five studies were Level IV evidence and one was Level III evidence. A total of 448 hips were evaluated. Study Findings The mean interval between the index procedure and revision surgery was 25.6 months. The mean patient age was 33.4 years, and 59.7% of total patients were female patients. The patient demographic data were similar in all 6 studies, as detailed in Table 1. Most of the studies reviewed indicated incomplete FAI treatment as the leading cause of revision surgery.22,25,27 FAI was treated in 37.9% of the index operations and 63.6% (range, 32% to 95%) of the revision operations (Fig 2). The studies in this review found that complete resection of cam pathology and complete resection of focal rim pathology,22-27 as assessed by postoperative radiographs, were positive predictive factors for improved functional outcomes after revision hip arthroscopy. Among the FAI cases, cam lesions were addressed by 29.8% of index operations and 37.2% of revision
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REVISION HIP ARTHROSCOPY
Fig 1. Outline of search strategy.
operations. Pincer lesions were addressed by 8.1% of index operations and 26.4% of revision operations (Fig 3). Labral repair or debridement was performed in 72.6% of index operations and 77.9% of revision operations (Fig 2). There were other procedures reported including cam and/or rim osteoplasty, chondroplasty, microfracture, psoas release, trochanteric bursectomy, loose body removal, capsular plication, thermal capsulorrhaphy, ligamentum teres debridement, and adhesiolysis in conjunction with FAI surgery. A detailed chart of various procedures performed during index surgery and revision surgery with weighted means is shown in Table 3. After initial revision hip arthroscopy, 14.6% of patients (reported in 4 of 6 studies) did not achieve satisfactory clinical improvement and pursued additional interventions, such as re-revision hip arthroscopy (8%), total hip replacement (5.6%), or hip resurfacing (1%). All studies examined in this review reported successful short- and intermediate-term outcomes with
revision hip arthroscopy.22-27 Although other outcome measures were used in some of the studies,24,25 they were not used consistently across all studies and, therefore, would not allow for any comprehensive comparisons. The outcome measure used across 50% of the studies was the modified Harris Hip Score (mHHS). Overall, the mHHS improved by a mean of 33.6% (19.3 points) from the baseline score at 1-year follow-up.
Discussion Key Findings This systematic review examined the indications for and outcomes of revision hip arthroscopy and reported favorable overall improvement in patient outcomes by a mean of 33.6% (19.3 points) on the mHHS, although 14.6% of patients underwent additional procedures for residual symptoms after a mean follow-up of 21 months.22-27 The results of this review show (1) short- to medium-term (12 to 36 months) improvement in patient outcomes (mHHS), with 33.6%
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Preoperative 62.1 NR 53.8 56 NR 55 57.4 Study Larson et al.25 Gwathemy et al.27 Aprato et al.26 Philippon et al.22 Heyworth et al.23 Domb et al.24 Mean
T Re Pr Pr Re Re Pr NA
L III IV IV IV IV IV NA
Year 2014 2014 2014 2007 2007 2014 NA
SS 85 192 63 37 24 47 448
MS 8 of 16 12 of 16 11 of 16 9 of 16 7 of 16 11 of 16 9.7
MA, yr 29.5 33 37 33 33.6 37.1 33.4
Female 44 116 36 25 14 26 261
Male 35 72 27 12 9 21 176
MFU, mo 26 12 36 12 NR 36 21
MIBR, mo NR 24 36 20.5 25.6 22 25.6 Gender
Table 1. Study Characteristics
L, level of evidence; MA, mean age; MFU, mean follow-up; mHHS, modified Harris Hip Score; MIBR, mean interval between index and revision surgery; MS, Methodological Index for NonRandomized Studies score; NA, not applicable; NR, not reported; Pr, prospective; Re, retrospective; SS, sample size; T, type of study.
mHHS
Change at 6 wk NR NR 0.33 NR NR 10 4.1
Change at 6 mo NR NR 7.8 NR NR NR 7.8
Change at 1 yr NR 22 9.7 21 NR 20 19.3
Change at 2 yr 17.8 NR 10.7 NR NR 15 14.8
Change at 3 yr NR NR 4.4 NR NR 17 9.8
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improvement from baseline at 1 year after revision hip arthroscopy; (2) unaddressed or inadequately addressed FAI at index surgery as the most common indication for revision hip arthroscopy; (3) labral tears and chondral defects as other common concomitant indications for revision hip arthroscopy; and (4) associative findings of female predominance for revision hip arthroscopy (59.7%). Harris et al.,28 in their meta-analysis of 6,334 hips, reported that the reoperation rate after index hip arthroscopy was 6.8%, with 2.9% converting to total hip arthroplasty, whereas with revision hip arthroscopy, the reoperation rate was 14.6%, with 5.9% converting to total hip arthroplasty. In 2009 Philippon et al.29 reported outcomes of primary hip arthroscopy for FAI, with a mean improvement in the mHHS by 24 points. Nho and colleagues30 reported that the minimal clinically important difference for the mHHS in hip arthroscopy is 20.0 points at 1 year. Revision hip arthroscopy shows an improvement in the mHHS by 19.3 points at the 1-year mark, which is consistent with outcomes of primary hip arthroscopy and makes a clinically important difference. Thus revision hip arthroscopy does improve patient-reported outcomes to make a clinical difference but is not as successful as index hip arthroscopy in terms of the reoperation rate. The studies included in this review did not detail the cause of the higher reoperation rate. There could be various reasons for reoperation such as infection, prolonged rehabilitation, inadequate resection of FAI, and further labral tears and chondral damage because of the prolonged time between the initial presentation and treatment because the index operation was unable to adequately treat FAI. Interesting Findings The mean interval between index and revision hip arthroscopy was 25.6 months (range, 20.5 to 36 months), which may represent the approximate length of time it took for patients to be affected by their symptoms or function, consult a surgeon, obtain an investigation of the potential issues at hand, agree to the revision procedure, and undergo the revision procedure. Harris et al.28 reported a mean period of 16.4 months between index hip arthroscopy and reoperation. Therefore surgeons should consider incorporating a minimum 2-year follow-up after index hip arthroscopy. These data on timing should be considered with caution because the included studies rarely detailed the length of time from clinical presentation to the actual time of revision surgery. The studies showed that the patients who most commonly require a revision are female patients (59.7%) and young patients, with a mean age of 33.4 years. Laborie et al.31 and Hetsroni et al.32 have previously reported cam radiographic findings of FAI to
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Table 2. Results and Conclusions of Included Studies Author Larson et al.25
Gwathemy et al.27
Aprato et al.26
Philippon et al.22
Heyworth et al.23
Domb et al.24
Result The authors reported improved outcomes after arthroscopic hip revision surgery for residual FAI. These were found to be inferior to the index surgery. They compared revision surgery with index surgery for FAI, but they only included data for patients undergoing revision surgery for FAI. A total of 79 patients with a mean age of 29.5 years were reported. The labrum was debrided in 32% of hips, repaired in 57% of hips, and reconstructed in 9% of hips. More than 70% of their cases showed a chondral defect and/or recurrent or new labral disease that required treatment at the time of revision surgery. Residual cam-type deformity was often found. They reported improvements for FAI revision by 17.8 points (mHHS), 12.5 points (SF-12), and 1.4 points (VAS) compared with 23.4 points (mHHS), 19.7 points (SF-12), and 4.6 points (VAS) after index arthroscopic FAI correction. The authors presented an abstract at the 2014 meeting of the Arthroscopy Association of North America. Index FAI correction had been performed in 24.5% of patients, with an improvement of 25 points on the mHHS. Revisions focused on correcting FAI in 17% of patients, with an improvement of 19 points on the mHHS. In 21.3% of patients, previous correction of FAI had been performed and no further correction was needed, improving by 18 points on the mHHS. In 37.5% of patients, there was no FAI and no correction was needed, and the mHHS improved by 26 points. The mean preoperative mHHS for 63 patients was 54 points. The mean postoperative mHHS was 53 points at 6 weeks, 62 points at 6 months, 63 points at 1 year, 64 points at 2 years, and 59 points at 3 years.
The common clinical findings in patients requiring revision surgery were hip pain, decreased range of motion, and functional disability. Revision procedures were performed because of FAI (95%), labral lesions (87%), chondral defects (70%), adhesiolysis (62%), and previously unaddressed instability (35%). The mean time from index surgery to revision surgery was 20.5 months. Further procedures were needed after revision surgery in 13.5% of patients. They had a mean follow-up of 12.7 months. The mean interval between index surgery and symptoms was 6.1 months. Eight cases had a failed labral repair, which was addressed with labral debridement and removal of suture material. Of these 8 cases, 6 had bony impingement that was also addressed at the time of revision surgery. The authors reported the results of a 2-year follow-up of 47 revisions by hip arthroscopy. In 66% of hips, FAI that was unaddressed or inadequately addressed was present at the time of revision. The authors reported significant improvements in all patient-reported outcome scores at a mean of 29 months after revision. They also found improvement in the Non-Arthritic Hip Score by at least 10 points in 65% of hips and 20 points in 44% of hips.
Conclusion Greater postoperative head-neck offset, subspine/ AIIS decompression, labral repair/reconstruction, and capsular placation were significant predictors of better outcomes after index surgery.
The authors concluded that, overall, there was a 22-point improvement in the mHHS at a minimum follow-up of 12 months, with 87% of patients showing improvements in measurable outcomes.
The authors found acetabular chondral lesions to be the major cause of revision hip arthroscopy. Of their patients, 31% underwent revision because of persistent FAI, and this cohort of patients did not do well regarding patientreported outcome scores at the 3-year mark. FAI was the major cause of revision hip arthroscopy. The authors also suggested the need for labral lesions and other soft-tissue abnormalities to be addressed because they are essential to the longterm success of the treatment of bony abnormalities.
The authors concluded that failure to address bony impingement and soft-tissue defects, such as a tight psoas tendon, are the major reasons for revision hip arthroscopy. They also concluded that failure of labral repairs in index surgery could be a result of unrecognized bony impingement. The authors concluded that pincer impingement, cam impingement, symptomatic heterotopic ossification, previous open surgery, and segmented labral defects treated with labral reconstruction were positive predictive factors for improved functional outcomes after revision hip arthroscopy. FAI was reported as a significant factor for the failure of hip arthroscopy.
AIIS, anterior inferior iliac spine; FAI, femoroacetabular impingement; mHHS, modified Harris Hip Score; SF-12, Short Form 12; VAS, visual analog scale.
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abnormalities. The reason for the increased revision of acetabular-sided lesions and in female patients is unknown and prompts further investigation.
Fig 2. Comparison of procedures performed during index versus revision hip arthroscopy: chondroplasty (C), microfracture (M), labrectomy (LT), labral repair (LR), femoroacetabular impingement correction (FAI), psoas release (P), trochanteric bursectomy (TB), loose body removal (LBR), capsular plication (CP), thermal capsulorrhaphy (TC), ligamentum teres debridement (LTD), and adhesiolysis (A).
be common in healthy young male patients. In addition, women are known to have a higher prevalence of pincer-type deformities.33 The percentage of acetabulum-based corrections performed during the revision operations (26.9%) was higher than the reported prevalence during index hip arthroscopy (11% according to Harris et al.28). Nepple et al.34 recently reported that female patients tend to have higher symptomatology with milder morphologic
Fig 3. Breakdown of femoroacetabular impingement into cam and pincer impingement for comparison of index versus revision hip arthroscopy.
Femoroacetabular Impingement The studies that did not subspecify FAI explicitly into cam- and pincer-type deformity may have represented mixed pathology and, when combined, resulted in FAI as the greatest cause of revision (64.3%). FAI correction was performed in 37.9% of index procedures, which is consistent with the literature.28 The results suggest that pincer-type lesions were addressed 3 times more frequently at revision hip arthroscopy (26.4%) when compared with index hip arthroscopy (8.1%). Nevertheless, cam-type impingement (37.2%), either unaddressed or inadequately addressed, was more commonly the cause for revision when compared with pincer-type impingement (26.4%). It is crucial to note that revision surgery in which a labral tear was the sole issue addressed was a rare finding, with most of the revision operations being combined with surgical management of FAI or chondral defects. This review showed that there was not a difference in the number of index operations versus revision operations performed for isolated labral pathology. In contrast, the percentage of FAI lesions treated during revision surgery nearly doubled when compared with index surgery. In 2001 McCarthy et al.35 concluded that labral injury through impingement at the extremes of motion leads to a series of progressive events including labral fraying, tearing, cartilage delamination, and finally, labral and cartilage degeneration. Consequently, incomplete FAI treatment during index surgery may result in further cartilage and labral pathology being seen and treated during revision hip arthroscopy. FAI pathology being treated during revision arthroscopy may be the result of recurrence or inadequate treatment during index surgery. None of the studies included in the review detailed the alpha angle correction during the index operation to determine if the alpha angle seen before revision hip arthroscopy changed in the period between index and revision surgery or was not adequately addressed at the time of index surgery. The osseous bump regrowth rate is believed to be 16% despite adequate resection, although Gupta et al.36 have recently shown that cam lesions after adequate osteoplasty do not tend to regrow when followed for a period of 2 years.37 Zaltz et al.38 have concluded that certain acetabular and extra-articular pathomorphologic entities are better treated with an open approach than with an arthroscopic approach. In addition, Bedi et al.39 have evaluated the efficacy of arthroscopic and open surgery regarding alpha angles and concluded that symptomatic posterolateral cam morphology can be effectively treated with an open approach. Furthermore, Matsuda
7
REVISION HIP ARTHROSCOPY Table 3. Procedures Performed During Index and Revision Hip Arthroscopy With Weighted Means
Index hip arthroscopy Chondroplasty Microfracture Partial labrectomy Labral suture Cam excision Pincer excision Psoas release Trochanteric bursectomy Loose body removal Capsular plication Thermal capsulorrhaphy Ligamentum teres debridement Adhesiolysis Revision hip arthroscopy Chondroplasty Microfracture Partial labrectomy Labral suture Cam excision Pincer excision Psoas release Trochanteric bursectomy Loose body removal Capsular plication Thermal capsulorrhaphy Ligamentum teres debridement Adhesiolysis
Larson et al.25
Gwathemy et al.27
Aprato et al.26
Philippon et al.22
Heyworth et al.23
Domb et al.24
Mean
Sample Size
NR NR NR NR NR NR NR NR NR NR NR NR NR
NR NR NR NR NR NR NR NR NR NR NR NR NR
34 3 30 4 20 3 4 0 NR NR NR NR 0
17 9 25 7 10 5 NR NR 6 6 4 6 NR
NR NR 16 8 7 2 1 NR NR 1 1 4 NR
NR NR NR NR NR NR NR NR NR NR NR NR NR
51.0% 12.0% 57.3% 15.3% 29.8% 8.1% 5.7% 0.0% 16.2% 11.5% 8.2% 16.4% 0.0%
100 100 124 124 124 124 87 63 37 61 61 61 63
NR 7 83 NR NR NR NR NR NR 23 NR 80 54
88 14 80 NR 66 32 17 NR 17 NR NR 34 56
19 10 15 10 12 8 9 6 NR NR NR NR 7
28 18 23 9 28 17 NR NR 10 10 3 21 15
NR NR 19 2 8 14 7 2 7 1 1 NR NR
20 4 27 18 21 25 17 NR 12 14 NR 7 NR
45.7% 12.5% 55.1% 22.8% 37.2% 26.4% 15.3% 9.2% 15.3% 24.9% 6.6% 39.3% 35.0%
339 424 448 171 363 363 326 87 300 193 61 361 377
NR, not reported.
et al.40 recently have shown that cam impingement extends beyond the described anterolateral quadrant of the proximal femur to the anteromedial corner. Pincer deformities occur in focal and global forms. Usually, global overcoverage of the acetabulum is challenging and is better treated with open surgical dislocation. Matsuda et al.41 have described dual-portal hip arthroscopy with central-compartment access, subtotal acetabuloplasty, and circumferential chondrolabral surgery. The size and location of the cam and pincer lesions being treated in the studies evaluated have not been reported in substantial detail. As such, it is unknown if the pathology being treated would be less challenging and more comprehensively addressed with an open approach to index surgery. Limitations This systematic review highlights the need for further investigation addressing this topic. Prospective randomized trials with a large number of participants and long-term follow-up would be ideal but might not be feasible because of the resource-intensive nature and methodologic challenges of such surgical trials.42 Further prospective cohort studies may be more feasible and less costly and will be able to compare the outcomes and failure rates with a group of patients who underwent index arthroscopic surgery.
There is a steep learning curve associated with FAI correctional surgery.43 The data in the studies included in this review are from centers where there is noted expertise and a high volume of hip arthroscopy procedures. Thus the reported results may not be generalizable to surgeons in lower-volume centers or with lesser expertise. Because there have also been significant advances in imaging and postoperative rehabilitation, further studies should be conducted incorporating how these factors affect the outcomes of revision hip arthroscopy. It would be ideal to compare what exact diagnostic modalities, such as intra-articular injections, clinical examination findings, and imaging findings, were used in decision making before index and revision hip arthroscopy. Aprato et al.44 and Claßen et al.45 have independently shown poor outcomes if the FAI or chondral lesions are not treated within the first 6 months of the onset of symptoms. None of the studies in this review reported the timing of index surgery with respect to the initial onset of symptoms. This may have contributed to selection bias. Because our understanding of the biomechanics of the hip joint is improving, various extracapsular entities, such as subspine impingement and psoas impingement,46 ischiofemoral impingement, and greater trochanteric/pelvic impingement, will be
8
V. SARDANA ET AL.
considered. These entities are challenging to diagnose with current radiologic techniques and are usually diagnosed intraoperatively.38,47,48 It is possible that better recognition of these entities will allow for identification of causes of failure that were previously unknown. All of the studies evaluated used magnetic resonance imaging/MRI arthrogram and plain radiographs to diagnose the etiology of failure preoperatively but did not detail if any of the aforementioned entities were considered. In summary, the limitations of this review include low-quality evidence, inconsistent reporting, possible expertise bias, and unclear diagnosis information. The studies were either Level III or IV evidence, and 5 studies lacked a reported control group. Follow-up times were variable, and sample sizes were generally small. The studies were inconsistent regarding imaging modalities used and patient-reported outcomes. Hetaimish et al.49 have previously highlighted inconsistency of reported outcomes after FAI surgery and a need for consistency in reporting outcomes to compare studies. Most of the data findings in this review are therefore associative, not causative. Furthermore, many of the authors were also the primary surgeons and had noted expertise in hip arthroscopy, leading to possible expertise and selection bias in reporting of the study results. Finally, the pathology being treated was selected by the surgeon on the basis of radiographic findings but was not explicitly detailed to be the cause of pain.
Conclusions The current evidence examined in this review supports revision hip arthroscopy as a successful intervention to improve functional outcomes (mHHS) and relieve pain in patients with residual symptoms after primary FAI surgery, although the outcomes are inferior when compared with a matched cohort of patients undergoing primary hip arthroscopy for FAI. The main indication for revision is a candidate who has symptoms due to residual cam- or pincer-type deformity that was either unaddressed or under-resected during the index operation. However, it is important to consider that the studies included in this review are of low-quality evidence. Surgeons should consider incorporating a minimum 2-year follow-up for individuals after index hip-preservation surgery because revisions tended to occur within this time frame.
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