No difference seen in subjective results for hip arthroscopy after periacetabular osteotomy
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DALLAS — Investigators found no statistically significant difference in postoperative change in patient-reported outcome scores among patients who underwent hip arthroscopy after periacetabular osteotomy, according to a presenter at the American Association of Hip and Knee Surgeons Annual Meeting.
“Furthermore, patients undergoing index [periacetabular osteotomy] PAO or PAO plus hip arthroscopy both demonstrated no difference in subsequent hip arthroscopy outcomes,” Mario Hevesi, MD, said during his presentation. “Finally, given these findings, patients and surgeons alike should expect a guarded prognosis after hip arthroscopy for persistent pain following PAO.”
Hevesi and colleagues reviewed the Academic Network of Conservational Hip Outcomes Research database to identify 29 patients who underwent a total of 32 periacetabular osteotomies with subsequent arthroscopy. Investigators determined patient demographics, patient-reported outcome scores and total hip arthroplasty rates to assess the use of arthroscopy after PAO. After PAO, patients were followed for a mean of 3.9 years. At a mean of 1.5 years, patients underwent hip arthroscopy.
Results showed the mean preoperative lateral center edge angle was 17.5°. At the time of PAO, the lateral center edge angle was corrected to 32°. There were 23 patients who underwent concurrent hardware removal.
No patient-reported outcomes were statistically significantly different after hip arthroscopy. Preoperatively to postoperatively, the hip osteoarthritis outcome score changed from 56.5 to 58.1 and WOMAC changed from 73.7 to 69.7. The University of California, Los Angeles score changed from 6.6 preoperatively to 6 postoperatively. The Harris Hip Scale score was 63.6 preoperatively and changed to 65 postoperatively.
Hevesi noted two hips converted to THA at the final follow-up at 4 to 6 years after PAO and 3 to 5 years after hip arthroscopy.
Hevesi said, “Hip arthroscopy at the time of index PAO remains controversial to this day. Hip arthroscopy after PAO is even more controversial with limited available data.” – by Monica Jaramillo
Reference:
Hevesi M, et al. Paper 42. Presented at: American Hip and Knee Surgeons Annual Meeting; Nov. 7-10, 2019; Dallas.
Disclosure: Hevesi reports he is a pain consultant for Moximed.
Perspective
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Benjamin G. Domb, MD, FAAOS, FAOA
This outstanding study brings into focus an important problem in the world of hip preservation — that of the patient with persistent pain after PAO — and highlights the need for caution in surgical indications and choice of surgical procedures. In some cases, pain may arise from pathologies that can be treated arthroscopically, such as a tear of the labrum, unstable cartilage flap or FAI induced by overcorrection. Indeed, overcorrected PAOs led, in part, to the discovery of FAI.
In other cases, global degeneration of a hip after PAO may render futile any further attempts to preserve the hip, whether by arthroscopic means or otherwise. Some such cases may be better addressed with arthroplasty.
Today’s workup requires 3D evaluation of the bony anatomy, advanced imaging of cartilage, such as dGEMRIC, and comprehensive understanding of patient factors to appropriately indicate hip preservation vs. THR. Furthermore, advanced arthroscopic techniques, such as anatomic labral repair, segmental or circumferential labral reconstruction, capsular plication and precision in FAI correction, may enable more successful results of arthroscopy in challenging revision cases.
Finally, the emergence of concomitant PAO and arthroscopy may avoid need for subsequent arthroscopy, having made it possible to treat intra-articular pathologies at the time of the index PAO surgery, including labral tears, chondral flaps and cam-type FAI. To conclude, thorough workup, careful indications and an arsenal of surgical techniques in both hip arthroscopy and arthroplasty are required to meet the challenges presented by persistent pain after PAO.
Chair and fellowship director of American Hip Institute Research Foundation
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