Journal of Hip Preservation Surgery Vol. 5, No. 2, pp. 174–177 doi: 10.1093/jhps/hny014 Ajay Malviya Consultant Orthopaedic Surgeon - Northumbria Healthcare NHS Foundation Trust, Senior Lecturer, Regenerative Medicine - ICM, Newcastle University, 10 East Brunton Wynd, Newcastle upon Tyne, NE13 7BR, UK. E-mail: firstname.lastname@example.org The Journal of Hip Preservation Surgery (JHPS) is not the reported outcomes of pain, disability and perception of only place where work in the field of hip preservation may improvement over a 2-year period were collected. be published. Although our aim is to offer the best of the The primary outcome was the Hip Outcome Score (HOS; best, we continue to be fascinated by work that finds its 2 subscales: activities of daily living and sport). Secondary way into journals other than our own. There is much to measures included the International Hip Outcome Tool learn from it, so JHPS has selected 6 recent and topical (iHOT-33), Global Rating of Change (GRC) and return subjects for those who seek a summary of what is taking to work at 2 years. The primary analysis was on patients place in our ever-fascinating world of hip preservation. within their original randomization group. What you see here are the mildly edited abstracts of the Statistically significant improvements were seen in both original articles to give them what JHPS hopes is a more the groups on the HOS and iHOT-33, but the mean differ- readable feel. If you are pushed for time, what follows ence was not significant between the groups at 2 years should take you no more than 10 minutes to read. So here (HOS activities of daily living, 3.8; HOS sport, 1.8; iHOT: goes ... 33 and 6.3). The median GRC across all patients was that they “felt about the same” (GRC¼ 0). Two patients RANDOMIZED CONTROLLED TRIAL (RCT) assigned to the surgery group did not undergo surgery, and COMPARING ARTHROSCOPIC SURGERY 28 patients in the rehabilitation group ended up under- AND PHYSIOTHERAPY FOR going surgery. A sensitivity analysis of “actual surgery” to FEMOROACETABULAR IMPINGEMENT “no surgery” did not change the outcome. Twenty (33.3%) While the results of 2 multicentred trials (FASHIoN and patients who underwent surgery and 4 (33.3%) who did FAIT), both based in United Kingdom, have been recently not undergo surgery were medically separated from mili- presented and we are waiting to see them in print form, we tary service at 2 years. now have the first published RCT on this topic. The The authors concluded that at 2 years there was no sig- results however are not reflecting what the other published nificant difference between the groups, and most patients evidence suggests. perceived little to no change in status and one-third of mili- Mansell et al. aimed to determine the comparative tary patients were not medically fit for duty. The authors effectiveness of surgery and physical therapy for femoroa- acknowledged the limitations including a single hospital, a cetabular impingement syndrome in an RCT. Patients single surgeon and a high rate of crossover; all of these are were recruited from a large military hospital; of 104 eligible up for debate until the results of the other RCTs are patients, 80 elected to participate, and the majority published. (91.3%) were active-duty service members. No patients withdrew because of adverse events. The authors randomly EFFECTS OF ARTHROSCOPY FOR selected patients to undergo either arthroscopic hip sur- FEMOROACETABULAR IMPINGEMENT (FAI) SYNDROME ON QUALITY OF LIFE AND gery (surgery group) or physical therapy (rehabilitation group). Patients in the rehabilitation group began a 12-ses- ECONOMIC OUTCOMES sion supervised clinic program within 3 weeks, and patients One of the primary questions asked by health-care pro- in the surgery group were scheduled for the next available viders is the cost-effectiveness of hip arthroscopic interven- surgery at a mean of 4 months after enrollment. Patient- tion in terms of quality of life. Mather et al. examined V C The Author(s) 2018. Published by Oxford University Press. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/174/4996727 by Ed 'DeepDyve' Gillespie user on 20 June 2018 What the papers say 175 the societal and economic impact of hip arthroscopy by simultaneous bilateral hip arthroscopy through an interpor- high-volume surgeons for patients with FAI syndrome tal capsulotomy with each hip randomized to undergo cap- aged<50 years with noncontroversial diagnosis and indica- sular repair or not undergo such a repair. tions for surgery. This double-blind, randomized controlled trial included The cost-effectiveness of hip arthroscopy versus nonop- 15 patients (30 hips), with a mean age of 29.2 years, who erative treatment was evaluated by calculating direct and underwent simultaneous bilateral hip arthroscopy utilizing indirect treatment costs. Direct cost was calculated with a small (<3 cm) interportal capsulotomy for the treatment Current Procedural Terminology medical codes associated of FAI. The first hip treated in each patient was intraopera- with FAI treatment. Indirect cost was measured with the tively randomized to undergo capsular repair or no capsu- patient-reported data of 102 patients who underwent arth- lar repair. The contralateral hip then received the opposite roscopy and from the reimbursement records of 32 143 treatment. MRI was performed at 6 and 24 weeks postop- individuals between the ages of 16 and 79 years who had eratively, and the scans were analyzed by 2 musculoskeletal information in a private insurance claims data set. The in- radiologists. direct economic benefits of hip arthroscopy were inferred The patients and the radiologists were blinded to the through regression analysis to estimate the statistical rela- treatment performed on each hip. Capsular dimensions tionship between functional status and productivity. A were measured at the level of the healing capsulotomy site simulation-based approach was then used to estimate the and, for hips with a persistent defect, at locations both change in productivity associated with the change in func- proximal and distal to the defect. These values were then tional status observed in the treatment cohort between analyzed at both time points to assess the rate and the ex- baseline and follow-up. To analyze cost-effectiveness, 1-, 2- tent of capsular healing. and 3-way sensitivity analyses were performed on all varia- At 6 weeks postoperatively, a continuous hip capsule bles in the model, and Monte Carlo analysis evaluated the (with no apparent capsulotomy defect) was observed in 8 impact of uncertainty in the model assumptions. hips treated with capsular repair and 3 hips without such a Analysis of indirect costs identified a statistically signifi- repair. Of the 19 hips with a discontinuous capsule at 6 cant increase in mean aggregate productivity of $8968 after weeks, 17 were available for follow-up at 24 weeks postop- surgery. Cost-effectiveness analysis showed a mean cumu- eratively; all 17 demonstrated progression to healing, with lative total 10-year societal savings of $67 418 per patient a contiguous appearance without defects and no difference from hip arthroscopy versus nonoperative treatment. Hip in capsular dimensions between the treatment cohorts. arthroscopy also conferred a gain of 2.03 quality-adjusted The authors concluded that arthroscopic repair of a life-years over this period. The mean cost for hip arthros- small interportal hip capsulotomy site yields an insignifi- copy was estimated at $23 1206 $10 279, and the mean cant increase in the percentage of continuous hip capsules cost of nonoperative treatment was estimated at $91 seen on MRI at 6 weeks postoperatively compared with no 6026 $14 675. In 99% of the trials, hip arthroscopy was repair. Repaired and unrepaired capsulotomy sites pro- recognized as the preferred cost-effective strategy. gressed to healing with a contiguous appearance on MRI The work has demonstrated that FAI syndrome produ- by 24 weeks postoperatively. ces a substantial economic burden on the society which ROLE OF PLATELET-RICH PLASMA (PRP) may be reduced through the indirect cost savings and eco- nomic benefits from hip arthroscopy. in GREATER TROCHANTERIC PAIN SYNDROME—RESULTS OF A RANDOMIZED DOES FORMAL CAPSULAR REPAIR AT THE CONTROLLED TRIAL TIME OF HIP ARTHROSCOPY IMPROVE Continuing with the theme of generating high-level evi- CAPSULAR HEALING? dence, Fitzpatrick et al. from Australia have looked at Capsular repair at the time of hip arthroscopy is a matter the role of PRP injection in comparison with corticosteroid of debate, and it adds time to the procedure, additional for gluteal tendinopathy. cost in terms of equipment used, is technically challenging There were 228 consecutive patients referred with glu- and indeed it is not clear whether it improves the outcome. teal tendinopathy who were screened to enroll 80 partici- In a multicentred randomized controlled collaboration be- pants; 148 were excluded for various reasons. Participants tween centers in New Zealand and United States, the were randomized (1:1) to receive either a blinded gluco- authors have tried to evaluate the magnetic resonance corticoid or an PRP injection intratendinously under ultra- imaging (MRI) appearance of the hip capsule in patients sound guidance. A pain and functional assessment was with femoroacetabular impingement (FAI) who underwent performed using the modified Harris hip score (mHHS) at Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/174/4996727 by Ed 'DeepDyve' Gillespie user on 20 June 2018 176 A. Malviya 0, 2, 6 and 12 weeks and the patient acceptable symptom additional hips were considered symptomatic based on a state (PASS) and minimal clinically important difference WOMAC pain score of 10 and/or an mHHS of 70. (MCID) at 12 weeks. One hundred and twenty-two (79%) hips did not undergo Participants had a mean age of 60 years, a ratio of fe- THA and did not meet the criteria for symptoms, and male to male of 9:1 and a mean duration of symptoms these hips had a mean mHHS of 92.4, WOMAC pain sub- of>14 months. Pain and function measured by the mean scale score of 1.2 and UCLA Activity Score of 7.7 at a mHHS showed no difference at 2 weeks (corticosteroid: mean of 10.1 years. A higher risk of failure was associated 66.95 versus PRP: 65.23) or 6 weeks (corticosteroid: 69.51 with fair or poor preoperative joint congruency (odds ratio versus PRP: 68.79). The mean mHHS was significantly [OR]: 8.65; P ¼ 0.034) and with a postoperative lateral improved (P ¼ 0.048) at 12 weeks in the PRP group center-edge angle of >38 (OR: 8.04). A concurrent (74.05) compared with the corticosteroid group (67.13). head–neck osteochondroplasty was associated with a The proportion of participants who achieved an outcome decreased risk of failure (OR: 0.27; P ¼ 0.016). score of 74 at 12 weeks was 17 (45.9%) of 37 in the cor- This study demonstrates the durability of the Bernese ticosteroid group and 25 (64.1%) of 39 in the PRP group. PAO. Fair or poor preoperative joint congruency and ex- The proportion of participants who achieved the MCID of cessive postoperative femoral head coverage were found to more than 8 points at 12 weeks was 21 (56.7%) of 37 in be predictors of failure, while concurrent head–neck osteo- the corticosteroid group and 32 (82%) of 39 in the PRP chondroplasty in patients with an inadequate range of mo- group (P ¼ 0.016). tion after PAO was associated with a decreased risk of The authors concluded that patients with chronic gluteal failure. tendinopathy>4 months, diagnosed with both clinical and PREVIOUS HIP PRESERVING SURGERY radiological examinations, achieved greater clinical improve- ADVERSELY AFFECTS THE OUTCOME OF ment at 12 weeks when treated with a single PRP injection than those treated with a single corticosteroid injection. TOTAL HIP ARTHROPLASTY (THA) This subject has been explored in 2 recent studies; Osawa INTERMEDIATE-TERM HIP SURVIVORSHIP et al. from Nagoya, Japan, have looked at outcome of AND PATIENT-REPORTED OUTCOMES OF THA after periacetabular osteotomy (PAO) and Konopka PERIACETABULAR OSTEOTOMY: THE et al, from NY, USA, have looked at the same after hip WASHINGTON UNIVERSITY EXPERIENCE arthroscopic surgery. The Bernese periacetabular osteotomy (PAO) has been an Osawa et al. performed a case–control study of 27 alternative to arthroplasty for treating symptomatic acetab- (29 hips) patients who underwent THA after PAO (oste- ular dysplasia, but there have been few studies on the otomy group); their mean age at surgery was 57.2 years, intermediate-term outcomes of this procedure. In this and they underwent postoperative follow-up for a mean study, the authors assessed intermediate-term hip survival period of 3 years. and patient-reported outcomes of PAO . For the control group, after matching age, sex and From July 1994 to August 2008, 238 hips (206 patients) Crowe classification, they included 54 (58 joints) patients were treated with PAO. Sixty-two had a diagnosis other who underwent primary THA for hip dysplasia.The 2 than classic acetabular dysplasia, and 22 were lost to follow- groups demonstrated no significant difference in the pre- up. The remaining 154 hips (129 patients) were evaluated operative Harris hip score, each domain of the SF-36, at an average of 10.3 years postoperatively. Kaplan–Meier JHEQ and the VAS score of hip pain and satisfaction. The analysis was used to assess survivorship with an end point osteotomy group demonstrated significantly poor Harris of total hip arthroplasty (THA). Hips were evaluated using hip scores for gait and activity and JHEQ for movement at the University of California at Los Angeles (UCLA) the last follow-up. There was no significant difference in Activity Score, modified Harris hip score (mHHS) and each domain of the SF-36 and the VAS score of hip pain Western Ontario and McMaster Universities Osteoarthritis and satisfaction at the last follow-up. They concluded that Index (WOMAC) pain subscale score. A WOMAC pain previous PAO affects the quality of physical function in subscale score of 10 and/or an mHHS of 70 was con- patients who undergo subsequent THA. sidered to indicate a clinically symptomatic hip. Konopka et al. in a cohort of 5091 patients who Kaplan–Meier analysis revealed a hip survival rate of underwent hip arthroscopy, identified 69 patients who 92% at 15 years postoperatively. Eight (5%) hips under- underwent subsequent THA (46) or hip resurfacing went THA at a mean of 6.8 years. Twenty-four (16%) arthroplasty (23). Patients were matched to patients with Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/174/4996727 by Ed 'DeepDyve' Gillespie user on 20 June 2018 What the papers say 177 2. Mather RC, Nho SJ, Federer A et al. Effects of arthroscopy for fem- no history of hip arthroscopy. Patients who underwent oroacetabular impingement syndrome on quality of life and eco- THA with history of arthroscopy had lower postoperative nomic outcomes. Am J Sports Med 2018; 46: 1205–13. hip disability and Osteoarthritis Outcome Score Pain 3. Strickland CD, Kraeutler MJ, Brick MJ et al. MRI evaluation of (82 versus 93, P ¼ 0.003), stiffness (85 versus 93, P ¼ repaired versus unrepaired interportal capsulotomy in simultan- 0.01), sports and recreation (71 versus 88, P ¼ 0.003), eous bilateral hip arthroscopy: a double-blind, randomized con- quality of life (65 versus 866, P < 0.0001), WOMAC Pain trolled trial. J Bone Joint Surg Am 2018; 100: 91–8. 4. Fitzpatrick J, Bulsara MK, O’Donnell J et al. The effectiveness of (86 versus 93, P ¼ 0.03), WOMAC stiffness (80 versus 88, platelet-rich plasma injections in gluteal tendinopathy: a random- P ¼ 0.05) and Short Form-12 Physical Component Scores ized, double-blind controlled trial comparing a single platelet-rich (48 versus 54, P ¼ 0.008). They were less likely to be “very plasma injection with a single corticosteroid injection. Am J Sports satisfied” after arthroplasty (71% versus 89%, P ¼ 0.0008). Med 2018; 46: 933–9. It seems that both PAO and hip arthroscopy before hip 5. Wells J, Schoenecker P, Duncan S et al. Intermediate-term hip arthroplasty is associated with slightly poorer results in sev- survivorship and patient-reported outcomes of periacetabular oste- eral patient-reported outcomes. These results are relevant otomy: the Washington university experience. J Bone Joint Surg Am 2018; 100: 218–25. when consenting these patients for arthroplasty. 6. Osawa Y, Hasegawa Y, Seki T et al. Patient-reported outcomes in patients who undergo total hip arthroplasty after periacetabular osteotomy. J Ortho Sci 2018; 23: 346–9. REFERENCES 7. Konopka JF, Buly RL, Kelly BT et al. The effect of prior 1. Mansell NS, Rhon DI, Meyer J et al. Arthroscopic surgery or phys- hip arthroscopy on patient-reported outcomes after total ical therapy for patients with femoroacetabular impingement syn- hip arthroplasty: an institutional registry-based, matched drome: a randomized controlled trial with 2-year follow-up. Am J cohort study. JArthroplasty 2018. doi: 10.1016/j.arth.2018. Sports Med 2018. doi: 10.1177/0363546517751912. 01.012. Downloaded from https://academic.oup.com/jhps/article-abstract/5/2/174/4996727 by Ed 'DeepDyve' Gillespie user on 20 June 2018
Journal of Hip Preservation Surgery – Oxford University Press
Published: May 16, 2018
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