Name: Hip Arthroscopy: Current State of the Literature and Future Direction of Research
Uploaded: 2016-07-18T00:00:00Z
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VPT1-00667-EN | A | Hip Arthroscopy: Current State of the Literature and Future Direction of Research

Benjamin G. Domb

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Hip Arthroscopy: Current State of the Literature and Future Direction of Research

I'll review the current state of literature and future directions in hip arthroscopy. Now, if we look at the amount of literature to review, we can see this is thanks to Karl Works who passed this on to me earlier today in 1981. There was one study in 91, one study, and by the time we get to 2015, we got 163 studies. So a massively, exponentially growing amount of literature each year that goes by. So the task then for this talk is to summarize the literature on hip preservation in ten minutes or less. So I'm going to summarize it by saying hip arthroscopy is really great. What we have learned from the literature I think in recent years. I'll go through a few things. And these are very broad brushstroke statements. I think we can take away hip arthroscopy is effective for Fe and labral tears. It's cost effective. Labral repair, generally speaking, is superior to labral resection. Labral reconstruction, while a technically challenging procedure, if performed in experienced hands, is a viable option for the irreparable or absent labrum. Microfracture may be useful for control defects in the hip. Capsular plication is effective in micro instability. Gluteus medius repairs seem to yield very favorable outcomes. Revision arthroscopy yields good outcomes as well, but the prognosis is more guarded. Hip arthroscopy is viable even in older patients, obese patients, and work comp patients. But we must lower our expectations in these groups. And iliopsoas lengthening has some literature for it and some literature against, thus remaining somewhat controversial. So the arthroscopic treatment of FAI, broadly speaking, is probably as good as or better than open treatment. Based on this systematic review that we recently published, we found favorable results for both. However, arthroscopy had better patient reported outcome scores in at least two of the four pros measured. And the table here, which you can review at your leisure, reviews some of the advantages and disadvantages of open versus arthroscopic techniques. Overall, if the repair work and bone work can be accomplished in an equivalent fashion, other arthroscopically or open arthroscopic technique is probably superior to the open technique. It's been important, as we've been part of a very new field, to establish the clinical outcomes. Anytime we're doing something new, we're out on a limb, and when we're out on a limb, we need to back up what we're doing with clinical outcomes research. The this will be the largest study to date that I'm aware of. On the clinical outcomes with minimum two year follow ups of hip arthroscopy. And this was recently presented at the Anna meeting and the Aossm specialty meeting. So hip arthroscopy showed significant improvement in all patient reported outcome scores, Vas satisfaction scores. Primary arthroscopy patients showed greater improvement on scores than the revision groups, and the relative risk of an arthroplasty was double for revision compared to primary procedures. So no great surprises. But I think as we try to explain to our patients what to what can be expected, how much evidence there is for what we're doing, and explain the same to the payers and insurance companies who are responsible for approving our patients care. It's my hope that this type of literature will help the field midterm results. This has yet to be published. This is our five year study. So minimum five year study 328 patients 82% survivorship. Significant improvement in all the patient reported outcome scores and high patient satisfaction. So this is a sneak peek at the preliminary results which hopefully will appear in print soon. Other studies that have been done are numerous. Numerous. This study by Asheesh Bedi was a comprehensive review of research published, published in Arthroscopy and Ajsm over three years. And the arthroscopic intervention resulted in improvement in functional outcomes at both short term and mid-term for patients with symptomatic FAI and the absence of significant existing degenerative changes. Labral repair may be a little bit better than debridement in this group, and you see the patient reported outcome scores were quite favorable. So it works now. Is it cost effective? This is an incredibly tedious thing to prove, and I learned more in this study than I ever wanted to know about the study of cost effectiveness, but I think it was a study that needed to get done. We recently presented this at an AA meeting, and this will be shortly in publication as well. And once again, I think this information will be helpful to all of us in this room and to all of our patients as we converse and collaborate with the insurers and payers to have surgery or treatment approved for our patients with with hip problems. By having shown the cost effectiveness, labral repair is probably superior to debridement or resection. Several studies on this now, some systematic reviews and some individual studies, as well as at least one randomized study. I won't go through each of these studies in detail. Labral reconstruction looks to be better than resection in the irreparable or previously resected labrum. This was a study that we did, which was a matched compare matched pair controlled study comparing reconstruction to resection. And not surprisingly, patients do better with a reconstructed labrum than with a resected labrum. Having said that, a reconstruction at this time remains an incredibly technically challenging procedure. And I think we'll talk later about how we hope that some of these techniques will be made easier with time. But at this point, I think reconstruction should be reserved for when you feel very comfortable, when a surgeon feels very comfortable with the technique. Other studies which have shown the efficacy of laser reconstruction out of Marc Philippon's group and and Microfracture. This was a three year follow up, recently published in Journal of Hip Preservation, and we compared patients who had a microfracture to those who didn't have a control defect at all. The thinking was that a chondral defect, even if it's treated with a microfracture, would portend a poorer prognosis compared to a patient who didn't have a control defect at all. And in fact, we did not find a difference between the groups showing that if treated with a microfracture control defect, need not necessarily portend a poorer prognosis, which I think is great news. Hip micro instability. I was always taught that the hip was an inherently stable joint, and I think over the last 5 to 10 years, we've figured out that that's not necessarily true. It doesn't typically dislocate like the shoulder does, but micro instability can be a source of rim damage, cartilage damage, labral damage, and ultimately pain. And this has been borne out in a number of number of studies, both clinical and biomechanical. The hip capsule and its ligaments are important for hip stability. That's a corollary statement, again shown in several biomechanical studies. And I would specifically point out our former fellow, Tim Jackson, did this excellent study, the bottom study here on the biomechanical effects of capsular shift in the treatment of micro instability as an answer to this problem. Similarly we proposed, along with Brian Giordano and Marc Philippon in this study several years ago, arthroscopic capsular repair and capsular plication for a traumatic instability. And subsequently, we published this study showing the outcomes of a pilot group of patients who had borderline dysplasia treated with capsular plication, and found that this was an effective answer in the context of labral repair for this group who had micro instability. Now revision hip arthroscopy is also effective, but the prognosis seems to be slightly more guarded. Multiple studies now demonstrating the outcomes of revision hip arthroscopy. So as we get into a second surgery, we need to counsel our patients. And if we get to third or fourth surgeries, we should potentially consider whether they will be of benefit to our patients. Age has generally been considered a negative prognostic factor, and it remains so. However, it appears that excellent outcomes can be achieved with the correct expectations even in the older group. In this study comparing patients over 50 to those under 30, we found the two year survivorship rate was indeed lower in the over 50 group 83% as opposed to 98%. But amongst the survivors, there was similar improvement in functional status. Other studies have shown that obesity is not necessarily a contraindication to hip arthroscopy, nor is workmen's compensation status, both of which may remain negative. Prognostic factors which cause us to adjust our expectations but need not necessarily be contraindications, and endoscopic gluteus medius tears can be managed. These can be managed endoscopically. They have very effective outcomes. This study recently in Jbj's showed 34 such patients with minimum two year follow up with excellent patient reported outcomes with respect to their functional status. Iliopsoas release or lengthening has had a number of good results published in the literature. There have also been some cautionary articles which have recommended against iliopsoas lengthening in many contexts. So I think it remains controversial. So the remaining controversies then, as I see them in the coming year or years. Age. Is there a limit for age on hip arthroscopy or how should we factor it into our indications? Iliopsoas lengthening. Is it our friend or our foe? What is the durability of capsular plication? Will it stretch back out or will this work for the long term? So as we think about the future, I think the future areas for research that need to be focused upon are the mid-term and long term results, which I hope will answer many of the concerns or skepticisms that have existed about our field. The question of can we change the natural history, i.e. can we delay or prevent osteoarthritis? In some of these patients, we need to improve our capsular management and capsular preservation. We need to further elucidate the role for biologic treatment for ChondroGuard. And ultimately we need to make hip arthroscopy easier to perform and easier to learn.

Hip Arthroscopy: Current State of the Literature and Future Direction of Research

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