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Editorial Commentary: Arthrosomnology and the Solution to Coxalgia Somnia: Arthroscopic Hip Surgeons and Patients Increasingly Appreciate the Role of Sleep as Good Medicine

      Abstract

      It is increasingly recognized that a variety of musculoskeletal disorders significantly influence sleep. In individuals with sleep dysfunction caused by hip pain (coxalgia somnia) from osteoarthritis, total hip arthroplasty has reliably improved pain and sleep quality in most patients. In nonarthritic, nondysplastic individuals with femoroacetabular impingement syndrome caused by cam and/or pincer morphology and labral tears, hip arthroscopy has similarly reliably improved pain and function in most patients. In addition, there is now early short-term evidence showing significant improvements in both sleep quantity and quality in most patients after arthroscopic hip preservation surgery. Integrating the realms of hip arthroscopy and sleep medicine, known as arthrosomnology, there are dozens of subjective patient-reported and objective clinician-measured outcomes available to analyze the impact of interventions. The Pittsburgh Sleep Quality Index is the most common subjective questionnaire used in orthopaedic surgery literature. Integrating the realms of wearable technology (fitness trackers, smart watches) and machine learning and artificial intelligence has incredible potential to collect immense volumes of accurate sleep “big data.”
      The United States alone loses nearly a half trillion dollars and 1.2 million working days per year as a result of insufficient sleep.
      Rand Corporation
      Why sleep matters—The economic costs of insufficient sleep: A cross-country comparative analysis.
      This problem extends to several other nations, including Canada, the United Kingdom, Japan, Germany, and Mexico.
      Sleepfoundation.org
      2013 International Bedroom Poll. OneCare Media, LLC..
      In addition to this incredible global economic impact, the burden imposed by sleep deprivation on societal health and social function cannot be emphasized enough. Low sleep quantity has been associated with 7 of the top 15 leading causes of mortality in the United States.
      • Kochanek K.
      • Murphy S.
      • Xu J.
      • Arias E.
      Mortality in the United States, 2013.
      On top of economics and health care, negative influences on job performance and school performance have received significant recent emphasis owing to loss in workplace productivity and increases in on-the-job accidents, traffic accidents, and even medical errors.
      • Nuckols T.
      • Bhattacharya J.
      • Wolman D.
      • Ulmer C.
      • Escarce J.
      Cost implications of reduced work hours and workloads for resident physicians.
      ,
      • Pack A.
      • Pack A.
      • Rodgman E.
      • Cucchiara A.
      • Dinges D.
      • Schwab C.
      Characteristics of crashes attributed to the driver having fallen asleep.
      For our youth, significant evidence has shown that decreased sleep quantity and quality may have staggering long-term consequences because of poor cognition and subsequent scholastic performance.
      • Blunden S.
      • Lushington K.
      • Kennedy D.
      • Martin J.
      • Dawson D.
      Behavior and neurocognitive performance in children age 5-10 years who snore compared to controls.
      • Owens J.
      • Spirito A.
      • McGuinn M.
      • Nobile C.
      Sleep habits and sleep disturbance in elementary school-aged children.
      • Roberts R.
      • Roberts C.
      • Chen I.
      Functioning of adolescents with symptoms of disturbed sleep.
      Unfortunately, within orthopaedic surgery, both attending surgeons and residents lack adequate sleep quantity and quality, worse than the general population.
      • Sochacki K.R.
      • Dong D.
      • Peterson L.E.
      • McCulloch P.C.
      • Harris J.D.
      The measurement of orthopaedic surgeon quality and quantity of sleep using a validated wearable device.
      The nocturnal impact of many orthopaedic conditions on our patients is widely and increasingly appreciated. Thus it is vital for our therapeutic interventions, especially surgery, to improve pain, function, quality of life, and, independently, sleep. That is why the study by Kunze, Rasio, Clapp, and Nho,
      • Kunze K.N.
      • Rasio J.
      • Clapp I.
      • Nho S.J.
      Improvements in sleep quality are maintained at a minimum of 2 years following hip arthroscopy for femoroacetabular impingement syndrome.
      “Improvements in Sleep Quality Are Maintained at a Minimum of 2 Years Following Hip Arthroscopy for Femoroacetabular Impingement Syndrome” is so critically important. This study is a minimum 2-year follow-up after their initial publication showing significant early (24 weeks) improvements in sleep quality after arthroscopic hip preservation surgery.
      • Kunze K.N.
      • Leong N.L.
      • Beck E.C.
      • Bush-Joseph C.A.
      • Nho S.J.
      Hip arthroscopy for femoroacetabular impingement improves sleep quality postoperatively.
      Within the world of hip preservation surgery, unfortunately there is very limited recent evidence. In nonarthritic individuals with femoroacetabular impingement (FAI) syndrome and acetabular dysplasia, sleep quality has been shown to be significantly affected.
      • Reddy N.
      • Martinez J.R.
      • Mulligan E.
      • Nakonezny P.
      • Wells J.
      Sleep quality and nocturnal pain in patients with femoroacetabular impingement and acetabular dysplasia.
      Eighty-nine percent and 79% of patients with dysplasia and FAI syndrome report poor sleep quality, respectively. The latter was determined using the Pittsburgh Sleep Quality Index (PSQI) scale, with scores of 9.0 ± 4.4 and 8.0 ± 4.3, respectively. The PSQI is one of the most common sleep scores used in orthopaedic surgery. It is a 19-question tool assessing sleep quality over the preceding month before the assessment.
      • Buysse D.J.
      • Reynolds 3rd, C.F.
      • Monk T.H.
      • Berman S.R.
      • Kupfer D.J.
      The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research.
      Total scores range from 0 to 21, with lower scores being better sleep and higher scores being worse sleep. Thus given the known influence of hip osteoarthritis on sleep,
      • Martinez R.
      • Reddy N.
      • Mulligan E.P.
      • Hynan L.S.
      • Wells J.
      Sleep quality and nocturnal pain in patients with hip osteoarthritis.
      it is not surprising to see similar effects on patients with prearthritic conditions, such as dysplasia and FAI syndrome. Most patients (74%) surgically treated for hip osteoarthritis with arthroplasty have shown significant improvements in sleep quality.
      • Van Meirhaeghe J.P.
      • Salmon L.J.
      • O'Sullivan M.D.
      • et al.
      Improvement in sleep patterns after hip and knee arthroplasty: A prospective study in 780 patients.
      To that end, Kunze et al.
      • Kunze K.N.
      • Leong N.L.
      • Beck E.C.
      • Bush-Joseph C.A.
      • Nho S.J.
      Hip arthroscopy for femoroacetabular impingement improves sleep quality postoperatively.
      analyzed 52 patients (mean age 37.8 ± 1.9 years) with FAI syndrome to determine if similar sleep quality improvements occur after hip arthroscopy in the short-term (3, 6, 12, and 24 weeks). Again using the validated PSQI and a threshold score of 5 or less as normal sleep and more than 5 as poor sleep quality, 94% of subjects had poor sleep quality preoperatively (mean 9.8 ± 0.6). After hip arthroscopy, the percentage of patients with normal sleep quality increased at each postoperative time point: 35% at 3 weeks, 58% at 6 weeks, 77% at 12 weeks, and 78% at 24 weeks (mean 2.2 ± 0.2). In analysis of sleep duration (just a single question in PSQI, scored 0 [>7 hours/night], 1 [6-7 hours/night], 2 [5-6 hours/night], or 3 [<5 hours/night]), patients went from 1.1 ± 0.2 preoperatively to 0.5 ± 0.1 at 3 weeks, 0.3 ± 0.1 at 6 weeks, 0.2 ± 0.06 at 12 weeks, and 0.09 ± 0.04 at 24 weeks after surgery (P < .001). The 2-year follow-up investigation published by Kunze et al.
      • Kunze K.N.
      • Rasio J.
      • Clapp I.
      • Nho S.J.
      Improvements in sleep quality are maintained at a minimum of 2 years following hip arthroscopy for femoroacetabular impingement syndrome.
      analyzed 37 patients out of the original 55 (67% follow-up). At 2 years, most patients (70%) had normal (PSQI ≤5) sleep quality (PSQI 4.3 ± 3.9, significantly better [P < .001] than preoperatively), showing that the 24-week outcome (PSQI 2.2 ± 0.2) was largely maintained (P = .06).
      These 2 studies form a good foundation for analysis of sleep quality and quantity after hip arthroscopy for FAI syndrome.
      • Kunze K.N.
      • Rasio J.
      • Clapp I.
      • Nho S.J.
      Improvements in sleep quality are maintained at a minimum of 2 years following hip arthroscopy for femoroacetabular impingement syndrome.
      ,
      • Kunze K.N.
      • Leong N.L.
      • Beck E.C.
      • Bush-Joseph C.A.
      • Nho S.J.
      Hip arthroscopy for femoroacetabular impingement improves sleep quality postoperatively.
      Easy areas to improve on the evidence include greater capture in follow-up (aim for >80%-90%), longer duration of data capture to reduce the chance of Hawthorne Effect, controlling for sleep quality and quantity confounders (e.g., caffeine use, medication use [especially sleep meds], supplement use [e.g., melatonin], television in bedroom, light amount in bedroom [e.g., lux meter, illuminance meter], amount of noise in bedroom, reporting of sleep partners [humans and pets], bedroom temperature, amount of daily exercise, presence/absence of sleep apnea), addition of control and comparison groups (nonsurgical treatment comparison [physical therapy]; natural history comparison [no treatment]; open surgery comparison [surgical dislocation, periacetabular osteotomy for dysplasia, femoral osteotomy]; peritrochanteric disorders, including gluteal repair and bursectomy; deep gluteal space disorders, including deep gluteal space endoscopy, sciatic, and posterior femoral cutaneous neurolysis, proximal hamstring repair, and ischiofemoral decompression; and patients with concomitant low back pain and hip-spine syndrome
      • Redmond J.M.
      • Gupta A.
      • Hammarstedt J.E.
      • Stake C.E.
      • Domb B.G.
      The hip-spine syndrome: How does back pain impact the indications and outcomes of hip arthroscopy?.
      ), age stratification as it is well-known that sleep needs change across youth and adulthood, comparison of sleep quality and quantity improvements based on sleep style (i.e., side-lying [fetal position], back, and front), statistical analysis of sleep quantity and quality on quality of life and a variety of other patient-reported outcomes, and addition of sleep medicine specialists to study design, conduct, and reporting. The latter can help with formal sleep studies such as polysomnography and analysis of the phases of sleep: light sleep, deep sleep (largely physically restorative phase), rapid eye movement (REM) sleep (largely mentally restorative phase), awake. Detailed objective analyses such as polysomnograms have huge advantages over the subjective PSQI, which is prone to significant recall bias and overestimation of sleep quality—patients largely equate time in bed to total asleep time and ignore sleep latency and disturbances. Wearable device technology has greatly improved in the recent past and can provide an accurate objective measurement of sleep quantity and quality. Advantages of wearables include their ease, efficiency, and cost, with resultant optimal compliance, as opposed to the polysomnogram, which is performed with attire and sensors not representing “usual” or “normal” or “typical” sleep hygiene and frequently not in the patient’s typical location (e.g., hospital, outpatient clinic, sleep center as opposed to their bed at home).
      In 2019, 21% of Americans reported wearing a smart watch or fitness tracker at all times during day and night.
      • Vogels E.
      About one-in-five Americans use a smart watch or fitness tracker.
      However, about half (51%) wear a fitness tracker at least once a day, frequently to measure calories burned during exercise, steps counted during an activity, or sleep monitoring.
      • Livernois C.
      Half of American use fitness trackers on daily basis.
      Monitoring sleep with wearable technology holds great promise. However, as more and increasingly complex data are added to the general population, their use and interpretation needs education and guidance. The aim of monitoring sleep is to make it better. However, the enemy of good is great. The perfectionistic quest to achieve perfect sleep may lead to a mental wellness disorder of sleep-related anxiety, termed orthosomnia.
      • Baron K.
      • Abbott S.
      • Jao N.
      • Manalo N.
      • Mullen R.
      Orthosomnia: Are some patients taking the quantified self too far?.
      Patients are actually seeking care from sleep specialists because their sleep tracker showed decreased sleep duration, increased awake and light sleep duration, decreased deep and REM sleep duration, increased disturbances, and abnormal latency. Although this level of data access for patients may be helpful and provide the opportunity for improved general health and wellness, it requires expert consultation and interpretation in many situations. Although machine learning and artificial intelligence are increasingly used and improved within health care, it is still in its relative infancy. Interpretation of sleep statistics offers an incredible opportunity for machine learning/artificial intelligence. In patients with sleep dysfunction caused by hip pain, coxalgia somnia, using a combination of subjective and objective outcome measures (especially wearable technology) can truly determine how arthroscopic and related surgery interventions impact patients’ lives (arthrosomnology).

      Supplementary Data

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