Hip arthroscopy for OA associated with high THA conversion rate
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Patients who underwent hip arthroscopy for osteoarthritis had a high conversion rate to total hip arthroplasty, as well as an increased risk of revision within 2 years, according to results.
Alexander S. McLawhorn, MD, MBA, hip and knee surgeon at Hospital for Special Surgery, and colleagues stratified patients into two groups based on whether they had undergone hip arthroscopy for OA prior to THA. Researchers considered the frequency of revision THA within 2 years of primary THA as the primary outcome, while other outcomes included revision for specific failure modes such as aseptic loosening, periprosthetic joint infection, periprosthetic fracturs and dislocation at 2 years after primary THA.
Among the 2,617 patients who underwent hip arthroscopy for OA, results showed a conversion rate of 68.4% to THA within 2 years. Researchers noted patients had an average time from hip arthroscopy to THA of 1.12 years. Patients who underwent hip arthroscopy prior to THA had a 3.7 times greater risk of revision hip replacement surgery compared with patients who did not undergo hip arthroscopy prior to THA, according to results. Researchers also found a 2.8 times greater risk of implant loosening and a 1.9 times higher risk of joint infection after hip replacement among patients who underwent hip arthroscopy prior to THA. Results showed 3.4% of patients in the arthroscopy group required revision surgery within 2 years of THA vs. 2.1% of patients in the non-arthroscopy group. Patients in the arthroscopy group also had higher rates of dislocation (3.2% vs. 2.3%), joint infection (2.9% vs. 1.6%) and joint loosening (2.3% vs. 1%) compared with the non-arthroscopy group, researchers noted.
“This study suggests that hip arthroscopy for hip arthritis in older patients is a low-value procedure,” McLawhorn told Healio Orthopedics. “The majority of identified patients went on to total hip replacement within 2 years of their arthroscopy, and hip arthroscopy was associated with worse outcomes in these patients after hip replacement was performed.” – by Casey Tingle
References: Hip arthroscopy for arthritis associated with unacceptably high conversion to total hip replacement and significantly worse outcomes. Available at: https://www.newswise.com/articles/hip-arthroscopy-for-arthritis-associated-with-unacceptably-high-conversion-to-total-hip-replacement-and-significantly-worse-outcomes. Accessed May 27, 2020.
Malahias MA, et al. Hip Int. 2020;doi:10.1177/1120700020911043.
Malahias MA, et al. Poster 0127. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2020 (meeting canceled).
Perspective
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Robert W. Westermann, MD
Michael Alexander Malahias Jr., MD, and colleagues performed an analysis of a U.S. Medicare database and identified patients who had hip arthroplasty and prior hip arthroscopy. All cases were performed in the setting of OA.
They found that during a 2-year postoperative period, about 70% of patients had been converted to THA. This is an unacceptably high failure rate. Hip arthroscopy should have a limited to an absent role in the management of hip OA, especially in elderly patients (Medicare in the present study).
Interestingly, they also found that prior hip arthroscopy in the setting of OA was not only associated with a high early conversion rate to THA, but these cases were subsequently more likely have THA failure and to undergo early revision THA. Hip arthroscopy is a useful tool that has demonstrated considerable clinical benefit for patients with femoroacetabular impingement syndrome in several multicenter, randomized controlled (Level 1) trials. These principles should not be used for treatment of patients with OA, period. This has been well established in the literature. The sobering finding of this study is that there is an association with even longer-term issues as patients with prior hip arthroscopy may be at increased rates of early revision THA.
While this is only a hypothesis and no definitive conclusions should be drawn from database studies such as this, it is intriguing and brings home the most important message: Don’t scope hips with OA – the negative effects could be further reaching than previously reported.
Timothy S. Brown, MD
Perspective
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John P. Salvo, MD
The potential increased complications in THA after hip arthroscopy is important information for arthroplasty surgeons. The authors looked at rate of revision THA and other complications 2 years post THA in two groups: those with previous hip arthroscopy for OA and those without it. Conversion rate from hip arthroscopy for OA to THA within 2 years was high and hip arthroscopy patients had increased risk for revision THA. The authors’ study group only had 18% of hip arthroscopy patients 64 years of age or younger and 58% were older than 70 years of age. This is not a typical patient population for hip arthroscopy.
Hip arthroscopy procedures have consistent, good results in multiple short- and mid-term outcome studies. Indications for hip arthroscopy include labral tears, femoroacetabular impingement (precursor to OA), loose bodies, etc.
Since hip arthroscopy is truly hip preservation, the consistent theme with best outcomes for hip arthroscopy is the status of the articular cartilage at time of index surgery. Those with healthy cartilage (Tönnis grade 0 or 1) can successfully undergo hip arthroscopy as a hip preservation procedure with reliable results. Those who have significant articular cartilage damage (Tönnis grade of 2 or greater) have poorer outcomes comparatively.
Appropriate candidates for successful hip arthroscopy are younger and have articular cartilage that is able to be preserved. OA is a contraindication to hip arthroscopy and may carry increased risk with subsequent THA.
References:
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Malahias MA, et al. Hip Int. 2020;doi:10.1177/1120700020911043.
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