Long-term Outcomes of Hip Arthroscopy in Workers’ Compensation Patients Compared to Non-workers’ Compensation Patients: A Propensity-Matched Study at Minimum 10-Year Follow-up

Abstract

Background:

Workers’ compensation (WC) patients often experience inferior outcomes compared with non-workers’ compensation (non-WC) patients after orthopaedic procedures. Long-term outcomes for contemporary hip arthroscopy in this group remain unclear.

Purpose:

To compare patient-reported outcomes (PROs), achievement of clinically significant outcomes, and reoperation-free survival between WC and non-WC patients undergoing hip arthroscopy for labral tear/femoroacetabular impingement syndrome at a minimum 10-year follow-up.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent hip arthroscopy between January 2012 and February 2015 with ≥10-year follow-up were included. WC patients were propensity-score matched with non-WC patients on age, sex, and body mass index. PROs were assessed preoperatively and at 2-, 5-, and 10-year postoperatively, including Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sport-specific (HOS-SS), Modified Harris Hip Score (mHHS), 12-item International Hip Outcome Tool (iHOT-12), and visual analog scale (VAS) for pain and satisfaction. Achievement of minimal clinically important difference (MCID), patient acceptable symptom state (PASS), and reoperation rates were compared.

Results:

A total of 37 WC hips were matched with 108 non-WC hips. Both cohorts demonstrated significant improvements in all PROs from baseline (P < .001). Preoperatively, WC patients had lower HOS-ADL (46.9 vs 63.5; P < .001) and mHHS scores (47.4 vs 57.3; P = .004), but similar HOS-SS and VAS-Pain scores (P≥ .076). At 2 years, WC patients reported lower HOS-ADL, HOS-SS, mHHS, and iHOT-12 scores (P≤ .047). At 5 years, HOS-ADL and HOS-SS remained lower in WC patients (P≤ .004), whereas other PROs were comparable (P≥ .160). At 10 years, no significant between-group differences persisted (P≥ .057). WC patients achieved higher MCID rates for HOS-ADL (94.7% vs 68.8%; P = .021) and mHHS (87% vs 62%; P = .038), with comparable MCID and PASS rates for other PROs. Both cohorts demonstrated similar reoperation-free survivorship (P = .383). Overall, 33 WC patients (91.7%) returned to work at a mean time of 8.7 ± 5.2 months postoperatively.

Conclusion:

At a minimum 10-year follow-up, WC patients demonstrated sustained improvement and outcomes comparable to non-WC patients after primary hip arthroscopy. Although WC status is associated with inferior preoperative and early postoperative outcomes, long-term symptom resolution, functional improvement, and joint preservation can be expected in appropriately selected patients treated with contemporary hip arthroscopy techniques.

Keywords

femoroacetabular impingement hip arthroscopy hip: hip/pelvis/thigh groin pain

In many orthopaedic procedures, workers' compensation (WC) patients often have inferior outcomes compared with non-WC patients, including longer recoveries, more complications, delayed return to work, poorer functional outcomes, and lower satisfaction.¹⁴ Therefore, WC patients are often excluded from clinical outcome studies, as patient outcomes after orthopaedic surgery are strongly influenced by the presence of WC.⁷ For patients who undergo orthopaedic surgical procedures, those receiving WC experience a 2-fold greater risk of a negative outcome.⁷

Hip arthroscopy for the treatment of femoroacetabular impingement syndrome (FAIS) is well studied, yet there are relatively few studies on WC patients. Horner et al¹⁶ found that at a minimum of 5-year follow-up, WC patients who underwent hip arthroscopy for FAIS had worse preoperative patient reported outcomes (PROs) (Hip Outcome Score activity of daily living scale (HOS-ADL), Hip Outcome Score sports-specific subscale (HOS-SS), International Hip Outcome Tool 12-Item (iHOT-12), and visual analog scale (VAS) for pain), had worse postoperative PROs (HOS-ADL, HOS-SS, VAS-Pain), and had a higher rate of revision hip arthroscopy surgery. Additionally, Sabetian et al³³ previously reported that hip arthroscopy can effectively treat labral tears in the setting of FAIS, regardless of WC status, but with inferior outcomes compared with non-WC patients. The authors found that WC patients showed significant improvements and high rates of returning to work at a minimum 5-year follow-up, but had lower PRO scores than the control group. Most recently, Domb et al⁹ demonstrated that hip arthroscopy for the treatment of FAIS and labral tears in patients with a WC claim was associated with favorable outcomes and a high return-to-work rate at a minimum 10-year follow-up. However, the WC patients had a significantly higher rate of revision hip arthroscopy than the non-WC patients. However, the cohort for this study underwent hip arthroscopy between 2008 and 2013, labral repair in only 52.9% of WC cases, and capsular release in most cases.⁹ This is contrary to contemporary hip arthroscopy techniques and may not accurately reflect long-term outcomes in patients undergoing contemporary hip arthroscopy.^6,11,20,24

To date, there is a paucity of long-term studies that assess the outcomes of contemporary hip arthroscopy for the treatment of FAIS and labral tears in WC patients. The primary objective of this study was to compare PROs between patients with WC and those without at a minimum 10-year follow-up after hip arthroscopy. The secondary objective of this study was to compare reoperation rates and conversion to total hip arthroplasty (THA) between patients with WC and those without WC at a minimum of 10 years of follow-up after hip arthroscopy. We hypothesized that patients with WC would have lower PROs, higher reoperation rates, and a higher conversion rate to THA after hip arthroscopy than those without WC.

Methods

Patient Selection

After obtaining approval from the local institutional review board (ORA: 25091401-IRB01), a prospectively maintained surgical repository of patients undergoing hip arthroscopy was retrospectively queried for WC patients undergoing primary hip arthroscopy for labral tear and/or FAIS between January 2012 and February 2015. The inclusion criteria were as follows: (1) confirmed WC status; (2) labral pathology present on magnetic resonance imaging and clinical examination (eg, reproduction of pain with flexion, adduction, and internal rotation test); (3) failed nonoperative treatment (eg, activity modification, oral anti-inflammatory medication use, physical therapy, and intra-articular injection); and (4) a minimum follow-up of 10 years. The exclusion criteria were as follows: (1) age <18 years at the time of surgery; (2) previous ipsilateral hip surgery; (3) concomitant procedures (eg, abductor repair, psoas lengthening, etc); (4) history of congenital hip disorder (eg, slipped capital femoral epiphysis, Legg-Calve-Perthes disease); (5) avascular necrosis; (6) staged/concomitant periacetabular osteotomy; (7) hip arthroscopy for secondary pathology other than labral tear/FAIS (eg, synovial chondromatosis, fibrous dysplasia, exostosis, or pigmented villonodular synovitis); or (8) missing minimum 10-year follow-up.

Surgical Technique

Patients with confirmed labral pathology with supporting physical examination findings who failed nonoperative management were indicated and gave consent for arthroscopic hip surgery. All arthroscopic hip surgery was performed by the senior author (S.J.N.), a fellowship-trained hip arthroscopic surgeon at a high-volume center using well-established techniques.^4,28 Patients were placed supine on a traction table with a padded perineal post under general endotracheal anesthesia. The operative extremity was prepared and draped in a standard sterile fashion. Anterolateral and mid-anterior portals were established, and an arthroscopic scalpel was used to incise the capsule between the 2 portals. When indicated, the acetabular rim was prepared, followed by labral preparation, labral repair, and management of any chondral defects to the acetabulum and/or femoral head. Traction was released, and attention was turned to the defects of the peripheral compartment. In cases that required increased exposure, the capsulotomy was extended vertically along the femoral neck (ie, T-type capsulotomy). Femoral osteochondroplasty was performed under fluoroscopic guidance, followed by dynamic examination to ensure complete resolution of osseous impingement. In all cases, capsular plication was performed using ultra-high-molecular-weight polyethylene sutures.

Patient Characteristics, Radiographic Information, and Intraoperative Information

Patient characteristics and preoperative information—including age, sex, body mass index (BMI), symptom duration, sports participation, back pain, job type, and WC status—were obtained via chart review. The reported occupations within the WC group were classified using the United States Department of Labor Classification system, which characterizes all occupations by the strength required to complete their daily duties.³² Standard pre- and post-operative radiographs were obtained for patients. The lateral center edge angle (LCEA), Tönnis grade, and Tönnis angle were assessed using the anteroposterior pelvis radiograph. The alpha angle was assessed using the Dunn view. The presence of chondral defects in the acetabulum and femoral head was collected intraoperatively. Beck classification was used to classify acetabular cartilage damage, and the International Cartilage Regeneration and Joint Preservation Society (ICRS) classification was used to characterize femoral head cartilage damage.^1,23,25,26 Procedures performed were recorded intraoperatively—including labral repair, acetabular rim decortication for preparation, femoral osteochondroplasty, capsular plication, and microfracture.

Postoperative Outcomes Analysis

PROs were collected preoperatively and at 2-, 5-, and 10-year follow-up. PROs collected include HOS-ADL, HOS-SS, mHHS, iHOT-12, VAS-Pain, and VAS-Satisfaction. Secure electronic data platforms were used to collect PROs (OBERD; PatientIQ). Patients who underwent revision surgery or conversion to THA were excluded from the final PRO analysis.

Clinically significant outcome thresholds and achievement were determined for the cohort, including the minimal clinically important difference (MCID) and the patient acceptable symptom state (PASS).^18,19,30 MCID thresholds were calculated using the distribution method, and PASS thresholds were determined using the anchor question method. Specifically, MCID thresholds were set at one-half the standard deviation of the difference between pre- and post-operative values for each PRO.^18,29 For PASS thresholds, patients were asked the binary anchor question: “Taking into account all the activities you have during your daily life, your level of pain, and also your functional impairment, do you consider that your current state is satisfactory?”, and outcomes were used to generate a receiver operating characteristic (ROC) curve based on the Youden index.^5,17,22 An area under the ROC curve of ≥0.70 was deemed clinically useful.⁵ PRO values exceeding the determined cutoff were deemed to have achieved MCID/PASS for the respective PRO.

Statistical Analysis

Continuous variables were reported as means ± standard deviations. All continuous variables were assessed for normality using the Shapiro-Wilk test and for variance using the F test. Paired data were compared using a paired t test or a Wilcoxon signed-rank test when normality was not achieved. Continuous variables were compared between groups using a 2-tailed t test, where normality was achieved, or a Mann-Whitney U test, where normality was not achieved. Ordinal data were reported as percentages and compared using the Fisher exact test. A log-rank test was performed to compare time-dependent reoperation-free survivorship between groups, which was defined as the absence of revision arthroscopy or conversion to THA. Groups were propensity-matched at a 1 to 3 case-control ratio based on age, sex, and BMI. The propensity-matching caliper was set to 0.20 to ensure rigorous matching, as this value has been shown to eliminate >98% of bias.² Statistical significance was set a priori to an α level of .05. All statistical analyses were performed in R, Version 4.5.1 (R Core Team; R Foundation for Statistical Computing).

Results

Patient Characteristics

A total of 37 WC hips (18 women; age, 39.7 ± 9.7; BMI, 28.3 ± 4.9) were propensity-matched to 108 non-WC hips (53 women; age, 39.0 ± 11.9 years; BMI, 28.2 ± 5.1) (Figure 1). There was no significant difference between groups regarding patient characteristics or follow-up time, except for sports participation, with a higher percentage of non-WC patients participating in sports (69.4% vs 29.7%; P < .001) (Table 1). Some included patients previously had their mid-term outcomes reported.¹⁶

Table 1

Cohort Characteristics ^a

	WC	Non-WC	P
Age, years	39.7 ± 9.7	39.0 ± 11.9	.770
Female	48.6	49.1	≥.999
BMI, kg/m²	28.3 ± 4.9	28.2 ± 5.1	.935
Sports participation	29.7	69.4	<.001
Back pain	32.4	19.4	.116
Psychiatric history	14.3	20.4	.619
Pain duration >2 years	16.7	29.0	.188
Follow-up time, years	10.4 ± 0.5	10.4 ± 0.4	.371

Data are presented as mean ± SD or %. BMI, body mass index; WC, workers’ compensation.

Radiographic Information

Preoperatively, there were no significant differences between the WC and Non-WC cohorts regarding alpha angle (66.0 ± 13.7 vs 63.3 ± 12.4; P = .297), LCEA (32.9 ± 6.8 vs 31.2 ± 6.4; P = .171), and Tönnis angle (5.3 ± 4.1 vs 7 ± 4.9; P = .089) (Table 2). The Tönnis grade was comparable between the 2 cohorts on preoperative radiographs (P = .798). Similarly, there were no significant differences postoperatively between cohorts for alpha angle (P = .167), LCEA (P = .372), or Tönnis angle (P = .150).

Table 2

Pre- and Postoperative Radiographic Parameters ^a

	WC	Non-WC	P
	Preoperative
Alpha angle, Dunn, deg	66.0 ± 13.7	63.3 ± 12.4	.297
LCEA, deg	32.9 ± 6.8	31.2 ± 6.4	.171
Tönnis angle, deg	5.3 ± 4.1	7.0 ± 4.9	.089
Tönnis grade, %			.798
0	86.5	82.4
1	13.5	17.6
	Postoperative
Alpha angle, Dunn, deg	38.1 ± 5.8	38.5 ± 4.1	.167
LCEA, deg	30.4 ± 5.7	29.4 ± 5.9	.372
Tönnis angle, deg	6.3 ± 4.3	7.7 ± 5	.150

Data are presented as mean ± SD. LCEA, lateral center edge angle; WC, workers’ compensation.

Intraoperative Findings and Operative Procedures

The rate of high-grade femoral head chondral defects (ie, ICRS >2) was comparable between the 2 groups (P = .112) (Table 3). However, the non-WC group had a significantly higher rate of high-grade acetabular chondral defects (ie, Beck >2) (P = .041). Both cohorts underwent labral repair, acetabular rim preparation, femoral osteochondroplasty, capsular plication, and microfracture at similar rates (P≥ .064).

Table 3

Intraoperative Findings and Procedures ^a

	WC	Non-WC	P
Labral repair	94.6	97.2	.602
Acetabular rim preparation	97.3	89.8	.297
Femoroplasty	100	99.1	≥.999
Capsular plication	100	99.1	≥.999
Microfracture	5.4	0	.064
Acetabular cartilage, Beck			.041
0-2	94.6	78.7
3-4	5.4	21.3
Femoral cartilage, ICRS			.112
0-2	100	91.7
3-4	0	8.3

Data are presented as %. The bold P value indicates statistical significance. ICRS, International Cartilage Regeneration and Joint Preservation Society, WC, workers’ compensation.

Patient-Reported Outcomes

There was significant improvement from baseline to 10 years postoperative for all PROs that were collected preoperatively and at 10 years for both cohorts (P < .001). Preoperatively, WC patients showed inferior HOS-ADL (46.9 ± 20.4 vs 63.5 ± 16.9; P < .001) and mHHS scores (47.4 ± 16.6 vs 57.3 ± 14.4; P = .004) but comparable HOS-SS and VAS-Pain scores (P≥ .076) compared with the control group (Table 4). At 2-year postoperatively, the WC group showed inferior HOS-ADL (73.6 ± 24.4 vs 87.4 ± 16; P = .004), HOS-SS (60.4 ± 31 vs 73.8 ± 25.5; P = .047), mHHS (67.7 ± 23.5 vs 80.5 ± 16; P = .007), and iHOT-12 scores (52.9 ± 29.4 vs 70.1 ± 27.4; P = .033). However, there was no difference in VAS-Pain or VAS-Satisfaction between the 2 groups at 2 years (P≥ .126). At 5 years postoperatively, the WC group showed lower HOS-ADL (66.9 ± 26.7 vs 84.6 ± 18.7; P = .001) and HOS-SS scores (56 ± 31.2 vs 76.4 ± 25.1; P = .004) compared with the control group. However, iHOT-12, mHHS, VAS-Pain, and VAS-Satisfaction were comparable between the 2 groups at 5 years (P≥ .160). There were no significant differences between the 2 cohorts for any PRO at 10 years postoperatively (P≥ .057). These results are summarized in Figure 2.

Table 4

Patient-Reported Outcomes ^a

	WC	Non-WC	P
	Preoperative
HOS-ADL	46.9 ± 20.4	63.5 ± 16.9	<.001
HOS-SS	30.8 ± 28.3	40.2 ± 23.9	.076
mHHS	47.4 ± 16.6	57.3 ± 14.4	.004
VAS-Pain	71.8 ± 21	69.8 ± 20.9	.694
	2-year
HOS-ADL	73.6 ± 24.4	87.4 ± 16	.004
HOS-SS	60.4 ± 31	73.8 ± 25.5	.047
mHHS	67.7 ± 23.5	80.5 ± 16	.007
iHOT-12	52.9 ± 29.4	70.1 ± 27.4	.033
VAS-Pain	28.5 ± 27.2	19.8 ± 23.8	.126
VAS-Satisfaction	82.1 ± 26.7	80.9 ± 27.3	.780
	5-year
HOS-ADL	66.9 ± 26.7	84.6 ± 18.7	.001
HOS-SS	56 ± 31.2	76.4 ± 25.1	.004
mHHS	71.6 ± 21.4	78.9 ± 19	.160
iHOT-12	63.6 ± 31.1	69.7 ± 29.8	.560
VAS-Pain	35.6 ± 28.9	27.7 ± 28.6	.224
VAS-Satisfaction	74 ± 37.9	73.3 ± 35.5	.547
	10-year
HOS-ADL	82.9 ± 21.3	85.6 ± 17.4	.816
HOS-SS	66 ± 29.3	75.1 ± 29.3	.057
mHHS	76.6 ± 15.1	77 ± 16.5	.710
iHOT-12	78.9 ± 21.1	75.5 ± 26.5	.630
VAS-Pain	23.7 ± 26	22.9 ± 26.2	.990
VAS-Satisfaction	90 ± 15.3	82.7 ± 28.1	.930
	Delta, preoperative–10-year
HOS-ADL	34.8 ± 17.3	18.6 ± 20.3	.002
HOS-SS	31.5 ± 31.9	32.5 ± 32.7	.915
mHHS	48.2 ± 28.6	26.9 ± 31.6	.006
VAS-Pain	–48.2 ± 23.6	–45.8 ± 33.3	.668

Data are presented as mean ± SD. Bold P values indicate statistical significance. HOS-ADL, Hip Outcome Score-Activities of Daily Living; HOS-SS, Hip Outcome Score-Sports Specific; iHOT-12, 12-item International Hip Outcome Tool; mHHS, Modified Harris Hip Score; VAS, visual analog scale; WC, workers’ compensation.

Clinically Significant Outcomes

Cohort-specific MCID and PASS thresholds were established for the following PROs, respectively: HOS-ADL (10.3, 76.9), HOS-SS (16.2, 62.7), mHHS (16.1, 73.6), and VAS-Pain (−15.2, 26.6). The cohort-specific PASS threshold for iHOT-12 was set at 74.6. However, MCID thresholds for iHOT-12 were not established given limited preoperative iHOT-12 data. At a minimum 10-year follow-up, WC patients had a higher rate of achieving MCID for HOS-ADL (94.7% vs 68.8%; P = .021) and mHHS (87% vs 62%; P = .038) than the control group. MCID achievement for all other PROs and for any PRO was comparable between groups (P≥ .110). Achievement of PASS was comparable between groups for all individual PROs and for achievement of PASS for any PRO (P≥ .141). These results are summarized in Figure 3.

Reoperation-Free Survival

The rates of reoperation-free survivorship were comparable between the 2 cohorts (P = .383) (Figure 4). Overall, 10.8% of patients in the WC group underwent reoperation compared with 16.7% in the non-WC group (P = .596) (Table 5). Revision surgery occurred in 5.4% of the WC group at a mean time of 5.8 ± 5.9 years and at 5.6% with a mean time of 3.0 ± 2.0 years in the non-WC group (P > .999). Conversion to THA occurred in 5.4% of the WC group at a mean time of 6.3 ± 5.9 years and in 11.1% of the non-WC group at a mean time of 5.1 ± 2.7 years (P = .519).

Table 5

Reoperation Rates ^a

	WC	Non-WC	P
Revision	5.4	5.6	≥.999
THA	5.4	11.1	.519
Any reoperation	10.8	16.7	.596

Data are provided as %. THA, total hip arthroplasty; WC, workers’ compensation.

Employment Type and Return-to-Work Status

Overall, 33 WC patients (91.7%) returned to work at a mean time of 8.7 ± 5.2 months postoperatively. Of these, 26 (72.2%) returned to full-duty work, and 7 (19.4%) returned to work with restrictions. Occupational reporting was available for 34 patients (94.4%). The most prevalent occupation strength level was medium, with 17 patients (47.2%) identified. The heavy-strength group included 6 patients (16.7%). Two patients (5.6%) reported a sedentary occupation, and 1 patient (2.8%) reported a very heavy occupation. The sedentary group returned to work the quickest, at 4.8 months, and the heavy strength group took the longest, at 10.2 ± 9.0 months. Three patients (8.3%) from the cohort were unable to return to work. Of these, 2 obtained permanent disability from a combination of WC claims related to spine injuries. The heavy strength group had the lowest return-to-full-duty rate, with 3 (50%) returning to full duty. These results are summarized in Table 6. In the non-WC group, 89 (84.0%) patients had occupational titles available to report. Of these, 37 (41.6%) patients reported sedentary occupations, 27 (30.3%) reported light occupations, 20 (22.5%) reported medium occupations, and 5 (5.6%) reported heavy occupations. No patients in the non-WC group reported a very heavy occupation.

Table 6

Return-to-Work Status ^a

	Sedentary	Light	Medium	Heavy	Very Heavy	Total
No. of patients	2 (5.6)	8 (22.2)	17 (47.2)	6 (16.7)	1 (2.8)	36 (100)
Time to return to work, months	4.8	9.9 ± 5.1	8.3 ± 5.3	10.2 ± 9.0	7.3	8.7 ± 5.2
Return to work
Full duty	2 (100)	5 (62.5)	13 (76.5)	3 (50.0)	1 (100)	26 (72.2)
With restrictions	0	2 (25.0)	4 (23.5)	1 (16.7)	0	7 (19.4)
No return	0	1 (12.5)	0	2 (33.3)	0	3 (8.3)

Data are presented as mean ± SD or n (%).

Discussion

The primary finding of this study is that, at a minimum of 10-year follow-up, patients with WC status demonstrated significant and durable improvement after primary hip arthroscopy, with outcomes and survivorship comparable to those of non-WC patients. Although WC patients showed inferior preoperative and 5-year outcome scores, these differences were not present at 10 years. Nearly all WC patients returned to work, with close to three-quarters returning to full duty at a mean of 8.7 months postoperatively. Together, these findings suggest that while WC status may predict delayed recovery after primary hip arthroscopy, long-term symptom resolution and joint preservation can be expected.

Previous reports have documented the correlation between WC status and lower short- to mid-term outcomes after primary hip arthroscopy. Horner et al¹⁶ reported 5-year outcomes and demonstrated that WC status was associated with worse postoperative outcomes at 5 years, with a higher rate of revision surgery than non-WC patients. Similarly, Sabetian et al³³ reported that WC status was associated with lower PRO scores, less clinically significant improvement, a higher rate of revision surgery, and a 66% return-to-work rate at 5 years postoperatively. In the present study, several outcome scores—including HOS-ADL and HOS-SS—were lower in the WC group at both 2- and 5-year postoperative follow-up. In addition to hip arthroscopy, the association of compromised outcomes in WC patients has also been documented in anterior cruciate ligament,³ rotator cuff repair,^15,31 and lumbar spine surgery¹³ outcomes. This phenomenon is multifactorial and may be explained by patient expectations, socioeconomic factors, adherence to treatment, or potentially secondary gain.

Despite a well-established association between WC status and compromised mid-term outcomes, the present study revealed that in the long term, WC patients perform similarly to their non-WC counterparts. Specifically, there was no difference in statistical measures, clinical significance, or rate of revision surgery. Domb et al⁹ also reported on a WC cohort with a minimum of 10-year follow-up and demonstrated that WC patients showed similar PROs and clinical significance achievement compared with non-WC patients. However, WC patients underwent revision surgery in 22.9% of cases, a rate significantly higher than in the control group. These results are similar to those of the current series regarding PROs and clinical significance, as both cohorts demonstrated that WC patients perform similarly at long-term follow-up. However, reports on revision rates vary, as the current series demonstrated a 5.4% revision rate in the WC cohort. These revision rate differences may be explained by a slightly more contemporary cohort in the current series, with patient enrollment starting in 2012 versus 2008, which may reflect a more modern arthroscopic technique. Additionally, capsular plication was performed in all cases in the current series, whereas capsular release was performed in 80% of the Domb et al⁹ series. Because the current series uses contemporary techniques, including labral repair and routine capsular closure, the findings of the present study are more reproducible in modern practice.

Rates of reoperation and survivorship were comparable between the WC and non-WC cohorts, challenging the idea that WC status compromises clinical outcomes and surgical durability. Further, the 10-year reoperation rate of 10.8% in the WC cohort is comparable to the previously reported survivorship of arthroscopic management of FAIS in both the general and athletic populations.^8,10,12 Interestingly, in the current series, WC patients achieved higher MCID rates for the HOS-ADL and mHHS than non-WC patients, likely reflecting greater relative improvement from lower preoperative baseline scores. Similar PASS rates suggest that the groups achieved comparable levels of pain and function. Together, these results suggest that WC patients can achieve favorable outcomes comparable to those of the general population with contemporary FAIS management.

Return-to-work rates were high overall in this study: 91.7% returned, and 72.2% returned to full duty. These results compare well with previously reported return-to-work rates of 70% to 90% after hip arthroscopy in WC populations.^9,21 The present analysis further delineates the influence of occupational demands. In this series, those engaged in heavy-strength occupations returned to work more slowly and less frequently than those in less demanding occupations. Together, these findings indicate that WC patients return to work at a high rate, with the majority returning to full duty. However, return to work is multifactorial and appears to be dependent to some degree on occupational demands.

Overall, this series demonstrated convergence in PROs between WC and non-WC patients at long-term follow-up. This finding may reflect the gradual attenuation of psychosocial factors that influence preoperative status and early recovery, resulting in a diminished impact over time. Previous studies have shown that WC patients often present with greater preoperative pain, lower self-efficacy, and increased psychological distress related to their injury.^27,34,35 With prolonged follow-up, however, our findings suggest that these factors exert less influence on clinical outcomes. Although the mechanisms underlying this complex relationship remain beyond the scope of the present study, potential contributors may include resolution of litigation, improved coping strategies, and patient adaptation to residual symptoms. Furthermore, the non-WC cohort demonstrated significantly greater acetabular cartilage damage at the time of surgery, which may also explain the attenuation of outcome differences at long-term follow-up. While this pathology may have had limited impact on early and mid-term recovery, its progressive degenerative effects could contribute to the observed convergence in PROs over time. Lastly, the greater proportion of athletes in the non-WC cohort may have affected clinical outcomes, as higher activity demands and expectations could influence patients’ perception of recovery.

Limitations

This study is limited by its retrospective nature, despite prospective data collection and propensity score matching. Further, the study was conducted at a single institution, a high-volume hip arthroscopy center, which may limit generalizability to other practices. This series reports on a relatively small number of patients, a feature inherent to this unique population and extended follow-up. The WC cohort was smaller by design due to 1 to 3 propensity matching and should be considered when interpreting the findings. Furthermore, 12 of 52 WC patients were excluded due to a lack of at least 10 years of follow-up, which represents an additional limitation of the study. Additionally, the return-to-work rates between the 2 groups were not reported. Lastly, the authors did not collect all variables that could explain the complex relationship between WC status and outcomes or return-to-work.

Conclusion

At a minimum 10-year follow-up, WC patients demonstrated sustained improvement and outcomes comparable to non-WC patients after primary hip arthroscopy. Although WC status is associated with lower preoperative and early postoperative outcomes, long-term symptom resolution, functional improvement, and joint preservation can be expected in appropriately selected patients treated with contemporary hip arthroscopy techniques.

Footnotes

Submitted November 5, 2025; accepted April 20, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: S.J.N. has received financial support from Stryker Orthopedics for intellectual property, as a consultant, and research support. S.J.N. also receives intellectual property royalties from Ossur and publishing royalties from Springer. S.J.N. serves as board member of the American Orthopaedic Society for Sports Medicine and the Arthroscopy Association of North America. K.I.B. is a consultant for BD Health and is a research committee member of the American Academy of Hip and Knee Surgeons.

Ethical approval for this study was obtained from the Rush University Medical Center (ORA: 25091401-IRB01).

ORCID iDs

Chandler A. Sparks

Shane J. Nho

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