Good outcomes found for both surgical dislocation and arthroscopy to treat FAI

However, arthroscopy showed a greater improvement in Level II matched-pair controlled study.

Issue: March 2014

Although researchers of a recently published single-surgeon prospective study that compared surgical dislocation of the hip to arthroscopy for the treatment of femoroacetabular impingement found improved patient-reported outcomes with both options, they discovered greater benefits with arthroscopy.

Perspective from John D. Kelly IV, MD

“Favorable results were shown with both approaches,” Timothy J. Jackson, MD, of Pasadena, Calif., said during his presentation at a recent meeting.

“There were significant improvements in outcome measures and high patient satisfaction ratings in both; however, arthroscopic treatment for femoroacetabular impingement showed higher Harris Hip and Non-Arthritic Hip Scores,” said Benjamin Domb, MD, of Hinsdale Orthopedics in Chicago, who performed the surgeries in this study.

Comparison of techniques

The study, performed at the American Hip Institute in Chicago, examined adult patients treated for femoroacetabular impingement between January 2008 and August 2011. They excluded patients with arthritis, dysplasia, Legg-Calves-Perthes disease or with a history of previous hip surgery. Patients were matched for age, gender and workers’ compensation status and elected to undergo either surgical dislocation or hip arthroscopy. There were 10 patients in the surgical dislocation group and 20 patients in the arthroscopy group. The mean patient follow-up was 24.8 months for the surgical dislocation group and 25.5 months for the arthroscopy group.

The surgical dislocation group underwent trochanteric flip osteotomy, allowing preservation of the muscular attachments during this joint-preserving open approach. Both open and arthroscopy groups underwent acetabuloplasty, femoroplasty, and labral repair. Both groups wore a hip brace for 2 weeks postoperatively. The surgical dislocation group was restricted in weight-bearing postoperatively to encourage trochanteric healing, according to Jackson.

Preoperative modified Harris Hip Scores, Non-Arthritic Hip Scores (NAHS) and Hip Outcome Score (HOS) subscales for sport (HOS-SSS) and activity of activities of daily living (HOS-ADL) were similar between the groups.

Outcomes

Both groups had favorable results, with significant improvements in outcome scores postoperatively at 3 months, 1 year and at the most recent follow-up, but the arthroscopy group had better outcomes for the absolute NAHS value and change in HOS-SSS. The NAHS was 88.1 points for the arthroscopy group compared to 75.3 points in the surgical dislocation group at 3 months, and 94.2 points for the arthroscopy group and 85.7 points for the surgical dislocation group at final follow-up. The change in HOS-SSS was 42.8 points for the arthroscopic group vs. 23.5 points for the surgical dislocation group at final follow-up. On a 10-point scale, the patient satisfaction for the arthroscopy group was 9.2 and 8.1 for the surgical dislocation group.

The alpha angle decreased in both groups. The angle went from 57° preoperatively to 40° postoperatively in the arthroscopy group and the measure dropped from 58° preoperatively to 40° postoperatively in the dislocation group.

“We sought to minimize selection bias by using a matched-pair study design with stringent matching criteria,” Jackson said. “We used the same intra-articular techniques, clinical protocols and rehabilitation (except for the weight-bearing in the surgical dislocation group). The approach became the primary variable.” – by Renee Blisard Buddle

Reference:

Domb BG. Am J Sports Med. 2014;doi:10.1177/0363546513508256.
Jackson T. Paper #47. Presented at: American Orthopaedic Society for Sports Medicine Annual Meeting; July 11-14, 2013; Chicago.

For more information:

Timothy J. Jackson, MD, can be reached at Congress Medical Associates Program, 800 S. Raymond Ave., Pasadena, CA 91105; email: timothyjjackson@gmail.com.
Benjamin G. Domb, MD, can be reached at Hindsdale Orthopaedics, and the American Hip Institute in Chicago, 1010 Executive Ct., Suite 250, Westmont, IL 60521; email: drdomb@americanhipinstitute.org.
Disclosure: Domb is a consultant for Arthrex Inc, Mako Surgical Corp., Pacira; has stock in Stryker and Mako Surgical Corp.; receives royalties from Orthomerica and DJO Global. Jackson has no relevant financial disclosures.

Perspective

John D. Kelly IV, MD

This study was well designed with thorough follow-up and good age-matching of subjects; however, there is no mention of factors that perhaps prompted the surgeon to perform open surgery (e.g., protrusio, coxa profunda). In addition, it is curious that patients would choose open surgery, knowing arthroscopy was an option; thus, there may have been factors that influenced treatment choice. Were the more difficult cases subtly encouraged to undergo arthrotomy?

Furthermore, the study is underpowered with 10 patients in the arthrotomy group. Yet, the conclusions are consistent with what hip arthroscopists hold true — that patient satisfaction is better when one avoids an arthrotomy. Hip arthroscopy affords excellent visualization of the intra-articular space and most of the peripheral acetabular rim. There was no compromise to femoral neck/cam access by the arthroscope as alpha angle reductions were similar in both groups.

The most sensitive evaluation instrument, the Hip Outcome Score–Sport-Specific Subscales, showed the greatest difference in outcome of - 42.8 in the arthroscopy group vs. 23.5 for the arthrotomy cohort.

Open surgical anterior hip dislocation, replete with trochanteric osteotomy to access the joint, is analogous to the knee arthrotomy used to access the meniscus prior to the late 1970s. Pain, soft tissue trauma and cartilage desiccation are a natural accompaniment to joint violation. Further, it is concerning that 80% of the arthrotomy patients required a second surgery for hardware removal.

To quote Clint Eastwood, “A man has to know his limitations” and we are obliged to do the best operation for our patients in our hands. To quote the great Jan Gilquist: “A good arthrotomy is always better than a bad arthroscopy.”

Even the best arthroscopists have to humbly admit that certain lesions, albeit rare (posterior and inferior labral and pincer lesions), are best accessed open.

Bottom line: Although this study is flawed, it does reinforce the notion that hip arthroscopy is here to stay. It behooves surgeons interested in treating hip disorders to attempt to learn it. I suspect that if an even more sensitive instrument (I-HOT 33) were used in this study, the patient satisfaction differences would be even larger and in favor of the arthroscopy group.

John D. Kelly IV, MD

Orthopedics Today Editorial Board member

Associate Professor of Clinical

Orthopaedic Surgery

Sports Medicine

University of Pennsylvania

Disclosures: Kelly has no relevant financial disclosures.