Psychiatric comorbidity quadruples failure ten years after hip arthroscopy

Design

Retrospective cohort, level 3 evidence, minimum 10-year follow-up

Population

243 adults after primary hip arthroscopy for femoroacetabular impingement syndrome, 2010-2014; 30.0 per cent with psychiatric comorbidity

Primary outcome

Failure (revision arthroscopy or conversion to total hip arthroplasty) and failure-free survivorship

Effect

Failure 23.3 per cent with psychiatric comorbidity vs 5.3 per cent without (P < 0.001); mean failure-free survivorship 11.49 vs 13.68 years (P = 0.0105)

Two hundred and forty-three adults who had primary hip arthroscopy for femoroacetabular impingement syndrome between 2010 and 2014 were followed to a minimum of ten years, with failure defined as revision arthroscopy or conversion to total hip arthroplasty. Preoperative psychiatric diagnoses were present in 73 patients (30.0 per cent) and psychotropic medication use in 51 (21.0 per cent).

Failure occurred in 26 patients overall (10.7 per cent), but the split was stark: 23.3 per cent among those with a psychiatric diagnosis against 5.3 per cent without (P < 0.001). Mean failure-free survivorship was 11.49 years against 13.68 (P = 0.0105), with lower survivorship at two, five and ten years. On adjusted multivariable analysis, anxiety, depression, the two combined, and psychiatric comorbidity with psychotropic use were each independently associated with higher odds of failure (all P at or below 0.002). Both groups improved on the modified Harris Hip Score and Non-Arthritic Hip Score, but those with psychiatric comorbidity improved less and finished lower.

This is a level 3 retrospective cohort and it shows association, not causation - untreated anxiety may worsen outcomes, or the same patients may have had more diffuse pain and less clear-cut impingement to begin with. Either way the change to practice is the same and is a change to consent rather than to indication. A third of the patients coming to hip arthroscopy carry this history; asking about it, quoting a materially different failure figure, and arranging the psychological input before the operation rather than after the disappointment is what the data support. What they do not support is refusing surgery on psychiatric grounds.

• Ask directly about anxiety, depression and psychotropic medication at the surgical consultation; 30 per cent will say yes.
• Quote a failure risk near one in four at ten years for these patients rather than the overall one in ten.
• Arrange psychological or pain-management input before the operation, not as a rescue afterwards.
• Set the expectation that improvement is real but smaller, using the patient-reported outcome data.
• Do not use this as grounds to decline surgery; the comorbid group still improved significantly.

The statistics, in plain English

A 23.3 against 5.3 per cent difference in 243 patients rests on 26 failures in total, so the estimate is directionally strong and numerically imprecise. This is a retrospective cohort at level 3 evidence, so the association cannot establish that treating the psychiatric condition would lower the failure rate. The mean survivorship difference of 2.19 years is a group average, not a prediction for any individual patient.

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