First Best Practices Guide for Femoroacetabular Impingement – https://ryortho.com/

How to help athletic patients with co-occurring femoroacetabular impingement (FAI) and osteitis pubis (OP)? In what is the first multicenter case series on this topic, Dean K. Matsuda, M.D., director of Hip Arthroscopy at the DISC Sports and Spine Center, has just published a study called, “Multicenter Outcomes of Endoscopic Pubic Symphysectomy for Osteitis Pubis Associated With Femoroacetabular Impingement.” Dr. Matsuda indicates that symphysectomy involves excision of the hyaline endplates and fibrocartilage of the symphysis pubis. He notes, “Retention of the inferior arcuate ligament is key as it is a primary stabilizer and our patients displayed no post-operative radiographic instability.”

According to the American Academy of Orthopaedic Surgeons, femoroacetabular impingement is “a condition where the bones of the hip are abnormally shaped. Because they do not fit together perfectly, the hip bones rub against each other and cause damage to the joint.” Osteitis pubis is defined as “inflammation of the pubis symphysis”

The study involved seven consecutive adult patients with a mean age of 33 years who underwent arthroscopic surgery for FAI and endoscopic pubic symphysectomy for OP (mean follow-up period of 2.9 years). The mean preoperative VAS score of 6.7 improved to a mean postoperative visual analog scale (VAS) score of 1.5. The mean preoperative Non-Arthritic Hip Score (NAHS) of 50.2 points improved to a mean postoperative NAHS of 84.7 points. The mean patient satisfaction rating was 8.3.

Asked what led to this research, Dr. Matsuda told OTW, “In 2008, a young athlete presented to our clinic with symptomatic bilateral femoroacetabular impingement and recalcitrant osteitis pubis. She successfully underwent bilateral arthroscopic surgeries for FAI and endoscopic pubic symphysectomy for her athletic OP. After publishing this as a case report in 2010, we have noted much interest in the topic of FAI and OP, the latter being just one of several conditions called athletic pubalgia [sports hernia]. A causative relationship is hypothesized that constrained range of hip motion from FAI causes an increase in transfer stress to the pubis symphyseal region [area of the pubis symphysis] with resultant OP. But at least one study showed that just performing FAI surgery did not consistently eradicate the central pubic symptoms from associated athletic publagia; concomitant procedures for FAI and OP were recommended, which is the basis of our work.”

“From the patient’s perspective, the ability to choose outpatient surgery for FAI and OP in co-afflicted athletes is very attractive.

Hunting the ever elusive objective measure of patient satisfaction could be an exercise in futility or it could be the most valuable initiative in years. A team of researchers from Rush University Medical Center in Chicago took up the challenge and have just published their results.

Their study, “Defining Meaningful Functional Improvement on the Visual Analog Scale [VAS] for Satisfaction at 2 Years After Hip Arthroscopy for Femoroacetabular Impingement Syndrome [FAIS],” appears in the November 14, 2019 edition of Arthroscopy.

Edward Beck, M.D., M.P.H., a co-author on the study, told OTW, “Over the past several years, there has been a trend in using patient satisfaction as a metric for surgeon performance, as well as a tool used for provider incentives and reimbursements.”

“However, we noticed that there is no clear objective level of patient satisfaction that defines postoperative clinical success. Recently, [there] has been a shift in the literature on how to define postoperative clinical success, from statistical differences between pre- and postoperative patient functional scores, to clinical differences in what patients consider as meaningful.”

“In order to identify patients we are helping the most, we set out to identify a satisfaction score.”

The authors prospectively collected data from consecutive patients who underwent primary hip arthroscopy between November 2014 and January 2017 and retrospectively analyzed the data. They included patients in the study who’d received a clinical and radiographic diagnosis of femoroacetabular impingement syndrome (FAIS), who’s also failed nonoperative treatment, who’d received primary hip arthroscopy to address their femoroacetabular impingement syndrome. Finally, the authors only used data that represented a minimum of minimum 2-year.

Ultimately, the team included 355 patients in their analysis.

Co-author Benedict U. Nwachukwu, M.D., M.B.A., summarized the results of their study to OTW, “We determined that over 85% of our patients reached the satisfaction score threshold for achieving the meaningful clinically important difference, which is what is considered the lower threshold of clinical success. The study also showed that higher BMI [body mass index] and a larger cam lesion are predictors of not achieving superior clinical success.”

In conclusion, said Beck, “There is a need for a more-nuanced approach to classifying the range of postsurgical successful clinical outcomes as value-based payments become more prevalent.

Smith & Nephew has recently launched its DYONICS PLAN Hip Impingement Planning System, a product that contrasts with standard imaging tools. DYONICS PLAN is a 3D software system that allows surgeons to visualize, assess and generate a comprehensive surgical report for each patient’s unique Femoroacetabular impingement (FAI) surgery before that patient ever enters the operating room.

DYONICS PLAN provides a standardized and repeatable way of assessing hip impingement treatment options based on data from low-dose CT scans. The software, which is easily installed on a surgeon’s computer, also allows for interactive adjustments based on a surgeon’s clinical experience.

Using the DYONICS PLAN 3D model of the patient’s joint, a surgeon can perform variety of dynamic range-of-motion (ROM) simulations to identify the degree and location of hip impingement. The ROM feature can also be used to individualize a surgical plan based on a patient’s lifestyle or sports-specific motion, or to assess impact of different surgical strategies on patient outcomes. Once finalized, the system generates a comprehensive surgical plan than can be exported into either HTML or PDF format.

Regarding the development process the Smith and Nephew product team told OTW, “The design of DYONICS PLAN was driven by our thought leaders from start to finish. Additionally, there was the inherent excitement of developing a first-of-its-kind technology, which challenged the entire team to develop several innovative solutions related to the 3D characterization of hip joint morphology and motion simulation. In the end, we have a product that we are confident will change the way that surgeons understand FAI correction planning and ultimately serve their patients.

DYONICS PLAN was designed in conjunction with four leading surgeons in hip arthroscopy: Dr. Asheesh Bedi of Ann Arbor, Michigan; Dr. J.W. Thomas Byrd of Nashville, Tennessee; Dr. Bryan Kelly and Dr. Christopher Larson of Edina, Minnesota.

A multicenter case-control study has tackled the issue of defining clinically meaningful outcomes after hip arthroscopy for femoroacetabular impingement (FAI).

The study, “Hip Arthroscopic Surgery for Femoroacetabular Impingement with Capsular Management: Factors Associated With Achieving Clinically Significant Outcomes,” was published in the November 21, 2017 edition of The American Journal of Sports Medicine.

Shane Nho, M.D. an orthopedic surgeon at Rush University Medical Center in Chicago, told OTW, “The field has been evolving over the past several years and the patient selection and surgical technique has also changed. Our paper is the largest series in the literature and represents the state of the art in hip arthroscopy for the treatment of femoroacetabular impingement (FAI).”

The authors wrote, “Data from an institutional repository of consecutive patients undergoing primary hip arthroscopic surgery with routine capsular closure for FAI that had failed nonsurgical management between January 2012 and January 2014 were prospectively collected and analyzed. Of 474 patients during the enrollment period, 386 (81.4%) patients were available for a minimum 2-year follow-up.”

“At a minimum of 2-year follow-up, the patients had statistically significant improvements in all patient-reported outcomes (HOS-ADL [Hip Outcome Score-Activities of Daily Living], HOS-SSS [Hip Outcome Score-Sport-Specific Subscales], and modified Harris Hip Score [mHHS]), with a 1.2% rate of revision hip arthroscopic surgery and 1.7% rate of conversion to total hip arthroplasty.”

“The MCID [minimal clinically important difference] was achieved by 78.8% of patients for the HOS-ADL, and the PASS [patient acceptable symptom state] was achieved by 62.5% for the HOS-ADL.”

“Younger age, Tönnis grade 0, and lower preoperative HOS-ADL score were associated with successfully achieving the MCID for the HOS-ADL. Younger age, larger medial joint space width, and higher preoperative HOS-ADL score were associated with achieving the PASS for the HOS-ADL.”

“Younger age, lower body mass index, non–workers’ compensation status, and lower preoperative HOS-SSS score were associated with achieving the MCID for the HOS-SSS. Younger age, Tönnis grade 0, running, and higher preoperative HOS-SSS score were associated with achieving the PASS for the HOS-SSS. Overall, 49.4% of patients achieved all 4 clinically significant outcomes: both the MCID and PASS for the HOS-ADL and HOS-SSS.”

Dr.

For NFL players, the return-to-sport rate and the postoperative performance level can be a real game changer.

Kyle R. Sochacki, M.D., an orthopedic surgeon at Houston Methodist Orthopedic & Sports Medicine in Houston, Texas, and colleagues investigated return to sport rates in particular after hip arthroscopy for femoroacetabular impingement (FAI) in their study, “Performance and Return to Sport After Femoroacetabular Impingement Surgery in National Football League Players” published online April 9, 2019 in Orthopedics.

During the study, Sochacki and colleagues looked at return-to-sport rate, postoperative career length and games per season, pre-and postoperative performance and postoperative performance compared with control players.

In total, 55 NFL players (63 surgeries) were included in the study (mean age, 27.5±3.4 years; mean years in NFL at time of surgery, 4.7±2.9). According to the data collected, 47 (84.1%) of the NFL players in the study returned to sport at a mean of 6.7±3.8 months after surgery. The researchers found no significant difference between either average games played per season (12.1±4.0 vs. 12.5±3.1; p > .007) or career length (3.5±2.1 years vs. 3.7 ± 2.2 years) when compared to the control players.

Interestingly, quarterbacks had better performance scores after surgery than the controls (p = .007).

Shane Nho, M.D., an orthopedic surgeon at Midwest Orthopaedics at Rush in Chicago, Illinois, oversaw the study and told OTW, “Hip pain from labral tears and femoroacetabular impingement (FAI) is a common injury in the NFL.”

“The study by Sochacki and colleagues shows that approximately 80% of professional football players that underwent surgery for FAI were able to return playing in NFL. Most football players took about 6 months to get back to play and there was no difference in career length and games player per season when compared to a group of NFL players without FAI.”

“In summary, FAI is common hip injury in the NFL but with modern, hip arthroscopy treatment about 80% of players are able to return to NFL without any effect on games played or career length.”