Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-2883-y

HIP

Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement Olufemi R. Ayeni • Forough Farrokhyar • Sarah Crouch • Kevin Chan • Sheila Sprague Mohit Bhandari



Received: 9 September 2013 / Accepted: 25 January 2014 Ó Springer-Verlag Berlin Heidelberg 2014

Abstract Purpose Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). However, little is known whether the type of response correlates with the post-operative functional outcomes. The purpose of this study is to document the ability of a diagnostic hip injection to predict short-term functional outcomes following arthroscopic surgical management. Methods A prospective cohort of 52 patients diagnosed with FAI who had an intra-articular hip injection prior to arthroscopic surgery was evaluated. A pain diary was used during the 2 weeks after hip injection to document response. In addition, the modified Harris Hip Score (mHHS) was administered preoperatively and 6 months post-operatively to assess functional outcomes. The relationship between response to an intra-articular hip injection and mHHS scores 6 months after FAI surgery was evaluated. Results Overall, 42 of 52 (81 %) patients diagnosed with FAI achieved pain relief from the hip injection. Outcomes according to mHHS scores improved significantly at the 6-month follow-up visit (19 points, 95 % CI 15–24, p = 0.001). The therapeutic utility of the hip injection suggested that lack of pain relief predicted a lack of functional improvement following arthroscopic surgery. O. R. Ayeni (&)  K. Chan  M. Bhandari Division of Orthopaedic Surgery, Department of Surgery, McMaster University Medical Center, 1200 Main St. West, Room 4E17, Hamilton, ON L8N 3Z5, Canada e-mail: [email protected] F. Farrokhyar  S. Crouch  S. Sprague  M. Bhandari Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada

Conclusion In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery. Level of evidence Level II. Keywords Intra-articular hip injection  Femoroacetabular impingement  Arthroscopic management  Surgical management

Introduction Femoroacetabular impingement (FAI) is a condition that arises when there is a size and shape mismatch between the femoral head and the acetabular rim. This condition causes hip pain in young adults and may be responsible for the development of osteoarthritis of the hip in later years [13]. With increased recognition of FAI, treatment strategies have been developed to address the related morphological changes, including open, arthroscopic, and combined surgical approaches [10, 12, 23]. Recent systematic reviews have shown that outcomes are similar regardless of the technique [5, 6, 20]. The diagnosis of an intra-articular hip condition is often confirmed with the use of an intra-articular hip injection. Byrd and Jones [8] demonstrated that the response to an intra-articular hip injection was 90 % accurate for diagnosing an intra-articular hip abnormality. Kivlan et al. [17] also showed that pain relief from an anaesthetic intraarticular hip injection was related to the presence of chondral damage in the hip joint. In spite of this knowledge about the diagnostic value of an intra-articular hip

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injection, there is limited information about the therapeutic predictive value of such a test. The purpose of this pilot study is to evaluate the relationship between an intraarticular hip injection and its ability to predict short-term functional outcomes following arthroscopic surgical management. It is hypothesized that a positive response to an intra-articular hip injection may predict positive clinical outcomes after surgical intervention.

Materials and methods Patients from the institution’s outpatient clinic were approached for study inclusion over a 1-year period if they were over the age of 16 with a clinical and radiological diagnosis of FAI. A clinical diagnosis was made when there was groin-based hip pain and a positive anterior impingement test. The anterior impingement test was considered positive when pain was recreated as the internally rotated hip was passively brought into approximately 90° of flexion and slight adduction [21]. Radiographs were evaluated for the presence of a bony prominence at the femoral head–neck junction (‘‘pistol-grip deformity’’), acetabular rim ossification, or acetabular retroversion; the latter was identified by crossover of the anterior and posterior acetabular walls on an anteroposterior radiograph of the pelvis [4, 19]. MR images were also assessed for FAI by identifying labral tears, particularly in the anterosuperior location, and an elevated alpha angle ([55°) [15, 19]. Exclusion criteria included previous hip surgery, paediatric hip disease, previous hip trauma, chronic pain, and ongoing litigation/compensation claims related to a hip condition.

the supine position utilizing traction (9.07–13.6 kg) and general anaesthetic. Mid-anterior and anterolateral portals were established, followed by an interportal capsulotomy to facilitate a traumatic central compartment access and to minimize potential chondral damage during entry [9]. Frayed and irreparable labral tissue was debrided; however, repairable labral tears or chondro-labral separations were repaired using one or two bio-absorbable anchors. Chondral lesions were addressed with debridement or microfracture at the discretion of the treating surgeon. Acetabular rim trimming was completed using a sheathed burr when a pincer lesion was identified. The peripheral compartment was addressed through a distal anterolateral portal. For a CAM decompression, a T-capsulotomy was completed along the head and neck junction of the femoral neck, and the lesion was resected using an arthroscopic burr. The lateral portion of the CAM lesion was addressed with the leg in extension, and once completed, the anterior CAM lesion was addressed with the hip flexed 45°. Adequacy of decompression of both CAM and pincer lesions was assessed with fluoroscopic X-rays intra-operative. Post-operative rehabilitation All patients started physical therapy within 1 week of surgery. The first 6 weeks of therapy included protected weight bearing and gentle supervised range of motion exercises. The next 6 weeks included the introduction of weight-bearing exercises with gait training. The next 3 months included functional and vocational rehabilitation exercises. Outcomes measures

Intra-articular hip injections Eligible patients with a diagnosis of FAI were then referred for an intra-articular hip injection prior to surgical intervention. The hip injection was administered by a musculoskeletal radiologist using a small amount of ionated contrast to confirm intra-articular placement under fluoroscopic guidance. The injection consisted of 5 mL of 0.25 % bupivacaine (Marcaine) and 40 mg of methylprednisolone acetate (Depo-Medrol, Pfizer, Canada). The hip joint was injected above the orbicular ligament using a maximum of 10 mL of solution. Surgical intervention Patients subsequently underwent arthroscopic surgery to treat their FAI condition with a combination of femoral neck osteochondroplasty, acetabular rim trimming, and labral debridement by a single surgeon (‘‘BLINDED BY REVIEWERS’’). Surgery was performed with the patient in

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Following hip injection, all patients were asked to keep a daily pain diary for 2 weeks to document their pain response categorically as either none, partial, or complete. ‘‘Partial relief’’ was defined as any degree of incomplete relief of hip pain compared to the level experienced prior to the injection. Conversely, ‘‘complete pain relief’’ meant that the patients were no longer experiencing any hip pain. Pain diaries have been used in other trials and provide an alternative method of documenting a patient’s subjective condition with the advantages of minimizing reliance on memory [7, 26]. Patients were encouraged to engage in provocative activities during the 2-week interval and to document any pain as a result of these activities on a daily basis. Two weeks following the injection, patients returned to clinic for reassessment. A research associate reviewed each patient’s diary to adjudicate the overall pain response to the intra-articular hip injection based upon the most frequently recorded, pre-specified category (none, partial, or complete pain relief).

Knee Surg Sports Traumatol Arthrosc Table 1 Summary of surgical procedures performed Type of procedure

Number performed

Labral debridement

45

Labral repair

Table 2 2 9 2 Table comparing IAHI and mHHS Pain relief and improved function at 6 months (mHHS [ 70 points)

8

Femoral head/neck osteochondroplasty

49

Acetabular rim trimming

32

Microfracture

6

Capsular release

3

Loose body removal

1

In addition, the modified Harris Hip Score (mHHS) was given at the first clinical visit (prior to surgery and the hip injection) and re-administered 6 months after surgical intervention by a research associate. The 6-month time frame was chosen because it was felt to be an important frame of reference for decisions affecting a patient’s return to sports, work, or recreational activities. The mHHS has two domains: pain (44 points) and function (47 points). A multiplier of 1.1 provides a total possible score out of 100. Scores were rounded up or down to the nearest whole number. The mHHS is a commonly used, patient-reported outcome measure in hip arthroscopies and has demonstrated good construct validity [25]. Patients with scores lower than 70 were considered as having an unsatisfactory result. This is based on a previous study that classified mHHS scores that were lower than 70 as fair or poor [1]. Ethics approval was obtained from our local research ethics board for this study (McMaster University), REB 10-168-D.

IAHI relieves pain (test ?) IAHI does not relieve pain (test -) Total

Total

Yes (true ?)

No (true -)

28

14

42

5

5

10

33

19

52

Likelihood ratio = 1.15 (for positive test); likelihood ratio = 0.57 (for negative test); sensitivity = 0.85; specificity = 0.26; positive predictive value = 0.67; negative predictive value = 0.50; accuracy = 0.63; prevalence = 0.63

no adverse reactions requiring secondary interventions after the intra-articular hip injection. The mHHSs improved from a mean of 56 points (standard deviation [SD] = 14 points) preoperatively to 75 points (SD = 18 points) at 6 months post-surgery (95 % CI 15–24 points, p = 0.001). Thirty-three patients (63.5 %) had a satisfactory mHHS (i.e. [70 points) at 6 months post-surgery. All patients that had negative outcomes (mHHS scores below 70) complained of soft tissue or muscular pain in the peri-operative sites (hip flexors and abductors). None of these patients have undergone repeat surgery. Two patients had repeat MR arthrograms due to severe pain symptoms, but they were negative for repeat labral tears, chondral damage, or residual impingement. Therapeutic utility of intra-articular hip injections

Statistical analysis Based on the surgeon’s practice, a recruitment rate of 75 % of eligible patients over a year or 50 patients for this pilot trial was anticipated. Standard tests of therapeutic accuracy, such as sensitivity, specificity, and likelihood ratios (LR), were calculated with 95 % confidence intervals. Mean mHHS scores for baseline, post-surgical, and change from baseline with 95 % confidence intervals (CI) were reported. The change in mHHS score was compared using paired t test. SPSS version 20.0 (www.IBM.com) and Stats Direct (www. statsdirect.com) software were used for data analysis.

Table 2 compares the results of the intra-articular hip injection and the functional outcomes after hip arthroscopy. The positive LR was 1.15 (95 % CI 0.85–1.56). This means that patients having pain relief from an intra-articular hip injection were 1.15 times more likely to experience improved function and decreased pain as a result of the surgery (as measured by a mHHS [ 70) compared to those without relief from an intra-articular hip injection. The more instructive finding was that the likelihood ratio for a negative test was 0.57 (95 % CI 0.10–1.73). This means that patients who did not receive pain relief from the intraarticular hip injection were half as likely to have better function and reduced pain at 6 months post-surgery.

Results There were 52 participants in this study with a median age of 37 years (range 16–62). Thirty patients (58 %) were females. Table 1 summarizes the type of operations performed. Forty-two (81.0 %) patients obtained complete or partial pain relief from the intra-articular hip injection. There were

Discussion The most important finding of the present study is that positive results from an intra-articular hip injection are only a weak predictor of success after FAI surgery

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(LR = 1.15). In contrast, a negative pain response from an intra-articular hip injection is more helpful (LR = 0.57), since it has a higher likelihood of ruling out a successful surgical outcome—that is, a satisfactory mHHS score. The utility of the test can be further demonstrated in a simple case scenario. If, after history, physical examination, and imaging, one estimates that there is an 80 % or moderate probability of surgically correctable FAI, then a negative intra-articular hip injection will reduce the post-test probability of a positive surgical outcome to 69.5 %. On the other hand, a positive test would increase the probability of a successful surgical outcome to only 82 %. Clearly, a positive test is far less informative than a negative test in this scenario, rendering the intra-articular hip injection’s value greatest when negative. Femoroacetabular impingement is increasingly being recognized and treated using hip arthroscopy [11]. Successful surgical outcomes must first require an accurate diagnosis. Previous studies have documented the diagnostic usefulness of an intra-articular hip injection to identify intraarticular hip abnormalities [8, 17]. Logically then, one might expect that a positive response to an intra-articular hip injection may predict positive clinical outcomes after surgical intervention. However, this study suggests that such an assumption is not completely accurate. This is the first study to document the therapeutic accuracy of intra-articular hip injection in patients undergoing FAI surgery. These results have important clinical implications, as both the surgeon and patient might assume that a positive response to an intra-articular hip injection will lead to satisfactory surgical outcomes, which would be contrary to the results of this study. It is important to note that the current study does not imply that intra-articular hip injections are clinically irrelevant, since they remain a valuable diagnostic tool to identify intra-articular hip disorders. However, orthopaedic surgeons should be mindful that it is not necessarily predictive of FAI surgical outcomes and patients need to be informed. Instead, previous studies have shown that underlying osteoarthritis may be an independent predictor of poor surgical outcomes [18, 22, 24]. Other predictors of outcomes may include preoperative mHHS scores and status of labral treatment (debridement vs. repair) [22]. The strengths of this study are its prospective nature and standard patient selection criteria using clinical and radiographic parameters, which are not always consistently reported in the literature [2, 3, 16]. In addition, all patients were treated by a single surgeon with 2 years of accredited formal training in arthroscopy. A recent internal audit also revealed that approximately 90 hip arthroscopic surgeries were being completed annually by the primary author. Likewise, all intra-articular hip injections were performed by a single musculoskeletal radiologist trained in

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interventional techniques. These factors help contribute to consistency in patient outcomes and reduce the potential for expertise bias. Finally, all patients were given a pain diary to document their injection response on a daily basis, which helps to minimize the impact of recall bias. The limitations of the study include the small sample size, which could lead to inadequate power. Patients were also followed for a relatively short interval (6 months), which may explain why the mean post-operative mHHS scores were lower than other published reports [9, 22]. However, as alluded to previously, the 6-month time period was chosen as a clinically relevant benchmark for both the clinicians and the patients. Furthermore, the current study was designed as a pilot trial to demonstrate feasibility and present preliminary results in order to facilitate future efforts to conduct additional longitudinal studies with larger sample sizes and longer follow-ups. Another limitation is that the patients presenting to this institution for surgical assessment may represent a subset of patients with more severe presentations of FAI who have failed non-operative management. Thus, the results of this study may not be generalizable to milder cases or the entire spectrum of patients with FAI. Finally, although the current study defined successful outcomes a priori as a mHHS score[70, there is still debate as to whether improvements from baseline state is more important than meeting absolute thresholds when assessing improvement [14]. The results of this study have important clinical implications as they will help the health care provider discuss both the diagnostic and predictive value of the intra-articular hip injection when counselling potential patients about surgical outcomes following intervention.

Conclusions In this study, the data suggests that a positive response from an intra-articular hip injection is not a strong predictor of short-term functional outcomes following arthroscopic management of FAI. However, a negative response from an intra-articular hip injection may predict a higher likelihood of having a negative result from surgery. Acknowledgments Research Chair.

Dr. Bhandari is funded in part by a Canada

Conflict of interest of interest.

The authors declare that they have no conflict

References 1. Aprato A, Jayasekera N, Villar RN (2012) Does the modified Harris hip score reflect patient satisfaction after hip arthroscopy? Am J Sports Med 40(11):2557–2560

Knee Surg Sports Traumatol Arthrosc 2. Ayeni OR, Wong I, Chien T, Musahl V, Kelly BT, Bhandari M (2012) Surgical indications for arthroscopic management of femoroacetabular impingement. Arthroscopy 28(8):1170–1179 3. Ayeni OR, Naudie D, Crouch S, Adili A, Pindiprolu B, Chien T, Beaule PE, Bhandari M (2013) Surgical indications for treatment for femoroacetabular impingement with surgical hip dislocation. Knee Surg Sports Traumatol Arthrosc 21(7):1676–1683 4. Beall DP, Sweet CF, Martin HD, Lastine CL, Grayson DE, Ly JQ, Fish JR (2005) Imaging findings of femoroacetabular impingement syndrome. Skelet Radiol 34(11):691–701 5. Bedi A, Chen N, Robertson W, Kelly BT (2008) The management of labral tears and femoroacetabular impingement of the hip in the young, active patient. Arthroscopy 24(10):1135–1145 6. Botser IB, Smith TW Jr, Nasser R, Domb BG (2011) Open surgical dislocation versus arthroscopy for femoroacetabular impingement: a comparison of clinical outcomes. Arthroscopy 27(2):270–278 7. Bridgman S, Walley G, MacKenzie G, Clement D, Griffiths D, Maffulli N (2006) Sub-vastus approach versus the medial parapatellar approach in primary total knee: a randomised controlled trial [ISRCTN44544446]. Trials 7:23 8. Byrd JW, Jones KS (2004) Diagnostic accuracy of clinical assessment, magnetic resonance imaging, magnetic resonance arthrography, and intra-articular injection in hip arthroscopy patients. Am J Sports Med 32(7):1668–1674 9. Byrd JW, Jones KS (2011) Arthroscopic management of femoroacetabular impingement: minimum 2-year follow-up. Arthroscopy 27(10):1379–1388 10. Clohisy JC, McClure JT (2005) Treatment of anterior femoroacetabular impingement with combined hip arthroscopy and limited anterior decompression. Iowa Orthop J 25:164–171 11. Colvin AC, Harrast J, Harner C (2012) Trends in hip arthroscopy. J Bone Joint Surg Am 94(4):e23 12. Ganz R, Gill TJ, Gautier E, Ganz K, Krugel N, Berlemann U (2001) Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br 83(8):1119–1124 13. Ganz R, Parvizi J, Beck M, Leunig M, Notzli H, Siebenrock KA (2003) Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orthop Relat Res 417:112–120 14. Impellizzeri FM, Mannion AF, Naal FD, Hersche O, Leunig M (2012) The early outcome of surgical treatment for femoroacetabular impingement: success depends on how you measure it. Osteoarthr Cartil 20(7):638–645

15. Kassarjian A, Belzile E (2008) Femoroacetabular impingement: presentation, diagnosis, and management. Semin Musculoskelet Radiol 12(2):136–145 16. Kivlan BR, Martin RL (2012) Functional performance testing of the hip in athletes: a systematic review for reliability and validity. Int J Sports Phys Ther 7(4):402–412 17. Kivlan BR, Martin RL, Sekiya JK (2011) Response to diagnostic injection in patients with femoroacetabular impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 27(5):619–627 18. Larson CM, Giveans MR, Taylor M (2011) Does arthroscopic FAI correction improve function with radiographic arthritis? Clin Orthop Relat Res 469(6):1667–1676 19. Maheshwari AV, Malik A, Dorr LD (2007) Impingement of the native hip joint. J Bone Joint Surg Am 89(11):2508–2518 20. Matsuda DK, Carlisle JC, Arthurs SC, Wierks CH, Philippon MJ (2011) Comparative systematic review of the open dislocation, mini-open, and arthroscopic surgeries for femoroacetabular impingement. Arthroscopy 27(2):252–269 21. Parvizi J, Leunig M, Ganz R (2007) Femoroacetabular impingement. J Am Acad Orthop Surg 15(9):561–570 22. Philippon MJ, Briggs KK, Yen YM, Kuppersmith DA (2009) Outcomes following hip arthroscopy for femoroacetabular impingement with associated chondrolabral dysfunction: minimum 2-year follow-up. J Bone Joint Surg Br 91(1):16–23 23. Philippon MJ, Schenker ML (2006) Arthroscopy for the treatment of femoroacetabular impingement in the athlete. Clin Sports Med 25(2):299–308 24. Philippon MJ, Schroder ESBG, Briggs KK (2012) Hip arthroscopy for femoroacetabular impingement in patients aged 50 years or older. Arthroscopy 28(1):59–65 25. Tijssen M, van Cingel R, van Melick N, de Visser E (2011) Patient-reported outcome questionnaires for hip arthroscopy: a systematic review of the psychometric evidence. BMC Musculoskelet Disord 12:117 26. Williams CM, Latimer J, Maher CG, McLachlan AJ, Cooper CW, Hancock MJ, Day RO, McAuley JH, Lin CW (2010) PACE–the first placebo controlled trial of paracetamol for acute low back pain: design of a randomised controlled trial. BMC Musculoskelet Disord 11:169

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Pre-operative intra-articular hip injection as a predictor of short-term outcome following arthroscopic management of femoroacetabular impingement.

Diagnostic hip injections are often used to confirm intra-articular pathology prior to arthroscopic treatment for femoroacetabular impingement (FAI). ...
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