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Editorial Commentary: Revision Hip Arthroscopy in Patients Older Than 40 Has a Higher Rate of Conversion to Total Hip Arthroplasty—Get It Right the First Time, and the Second

      Abstract

      Getting hip arthroscopy right the first time is critical to the overall patient outcome. This involves proper patient selection, with avoidance of arthritis, understanding the pathology of each hip, and properly executing the surgery. Care must be taken to restore labral function and preserve capsule function while accurately resecting pincer or cam impingement. While good results can be achieved in patients older than 40 years of age, an opportunity exists for improved optimization of clinical outcomes. Moreover, revision hip arthroscopy in patients older than 40 years of age has a higher rate of conversion to total hip arthroplasty. Again, get it right the first time, and carefully consider indications for revision hip arthroscopy in patients older than 40 years of age if there is a second time.
      The idea of getting it right the first time is obviously not unique to hip arthroscopy, nor is it is unique to orthopaedic surgery; in fact, it applies to just about everything in life. However, the results from the study entitled “Propensity-Matched Patients Undergoing Revision Hip Arthroscopy Over the Age of 40 Had Higher Risk of Conversion to Total Hip Arthroplasty Compared to Their Primary Counterparts” by Maldonado, Diulus, Lee, Owens, Jimenez, Perez-Padilla, and Domb
      • Maldonado D.R.
      • Diulus S.C.
      • Lee M.S.
      • Owens J.S.
      • Jimenez A.E.
      • Perez-Padilla P.A.
      • Domb B.G.
      Propensity-matched patients undergoing revision hip arthroscopy over the age of 40 had higher risk of conversion to total hip arthroplasty compared to their primary counterparts.
      reinforce that premise, as the headline number was a 2.6× higher rate of conversion to total hip arthroplasty in the older-than-40-years revision hip arthroscopy cohort.
      Why is it important to get it right the first time? The first reason is to avoid months or years of diminished quality of life for the patient. However, also, it appears from the results provided, once patients have gone from bad to worse after primary arthroscopy, they only get back to good. The preoperative patient-reported outcome (PRO) scores for those undergoing revision surgery were significantly lower than the primary group. This group is doing worse than those who had not yet had any surgery. The revision group then had significantly lower postoperative PRO scores and significantly lower patient acceptable symptom state rate. The good news is that there were similar rates of minimal clinically important differences, indicating some improvement can occur. The authors were somewhat optimistic in their interpretation of the results, and some hips were amenable to revision surgery, with a 74% survival rate at approximately 5 years. However, there is room for improvement in that survival rate and PRO scores.
      The most important factor in getting it right the first time, especially in patients older than 40 years of age, is patient selection. With increasing age, the most important variable is the cartilage. Hips are somewhat uniquely intolerant to any degeneration. In this study, the revision groups average age was 49 years, with 66% of those being female. In my experience, in a 50-plus female with hip joint pain, my first concern is chondrosis. This can vary from an acutely synovitic joint, presenting as a very irritable hip, to labral tearing with underlying chondrosis, which presents milder, more intermittent type pain. There are 2 types of cartilage damage in the hip, diffuse wear or chondrosis, which is usually graded on the Outerbridge scale, and localized damage adjacent to the labrum, measured by the acetabular labrum articular disruption scale. The difference as it relates to outcomes was supported in the study by the finding that the acetabular labrum articular disruption scale score was similar in the 2 groups, but almost one half of the revision cohort had Outerbridge cartilage greater than 2. Early chondrosis does not improve with age, and early chondrosis has joint space closer to 4 mm than 2 mm. For those still relying on >2 mm of joint space, especially on a 50-year-old female patient, as Walter Sobcek once said, “you are entering a world of pain.” Early chondrosis can become late, 0 mm, in a matter of months. For those with known chondrosis, an honest discussion should occur about viable nonsurgical alternatives such as platelet-rich plasma as a bridge to total hip arthroplasty rather than subjecting to another surgery with a relatively long recovery and guarded outcomes.
      We have been studying success and failures of hip arthroscopy for some time now.
      • Sardana V.
      • Philippon M.J.
      • de Sa D.
      • et al.
      Revision hip arthroscopy indications and outcomes: A systematic review.
      ,
      • Domb B.G.
      • Stake C.E.
      • Lindner D.
      • El-Bitar Y.
      • Jackson T.J.
      Revision hip preservation surgery with hip arthroscopy: Clinical outcomes.
      The most-cited cause of failure remains residual impingement. This may be easy to label, but do not get tunnel vision when approaching primary or revision surgery. The authors of this study have previously demonstrated a 30% conversion to total hip arthroplasty after revision arthroscopy in patients with previous over resection of cam lesions.
      • Mansor Y.
      • Perets I.
      • Close M.R.
      • Mu B.H.
      • Domb B.G.
      In search of the spherical femoroplasty: Cam overresection leads to inferior functional scores before and after revision hip arthroscopic surgery.
      Addressing over-resection is a very challenging problem, with few options available.
      • Arner J.W.
      • Ruzbarsky J.J.
      • Soares R.
      • Briggs K.
      • Philippon M.J.
      Salvage revision hip arthroscopy including remplissage improves patient-reported outcomes after cam over-resection.
      Unfortunately, this factor was not included in the recent study, but I think it is safe to say there may be some database output overlap.
      The most important and challenging component to revisions involves the labrum and capsule. Problematic labral repairs include labral tissue that is repaired in an overtensioned, everted manner or poor preservation of labral tissue with inadequate tissue remaining despite repair, both of which do not allow the labrum to provide the suction seal that is critical to restoring normal biomechanics. Recently, more attention has been given to the everted, hypoplastic labrum.
      • Vogel L.A.
      • Kraeutler M.J.
      • Jesse M.K.
      • et al.
      The everted acetabular labrum: Patho-anatomy, magnetic resonance imaging, and arthroscopic findings of a native variant.
      • Philippon M.J.
      • Bolia I.K.
      • Locks R.
      • Briggs K.K.
      Labral preservation: Outcomes following labrum augmentation versus labrum reconstruction.
      • Jackson T.J.
      Editorial Commentary: The everted acetabular labrum. It is not just a small labrum.
      These require careful repair techniques with mobilization of the labrum and possibly augmentation to achieve the suction seal.
      • Philippon M.J.
      • Bolia I.K.
      • Locks R.
      • Briggs K.K.
      Labral preservation: Outcomes following labrum augmentation versus labrum reconstruction.
      Regarding the capsule, capsule defects or capsular rents can cause very significant dysfunction (emphasis on very), and more recent studies on revisions have focused on capsule repairs and reconstructions as a means for significant clinical improvements.
      • Wylie J.D.
      • Beckmann J.T.
      • Maak T.G.
      • Aoki S.K.
      Arthroscopic capsular repair for symptomatic hip instability after previous hip arthroscopic surgery.
      It is worth noting the capsule was not repaired in 75% of the revision cohort. I presume most of this was done early in the study period, given what we think of the capsule now.
      I personally have experienced success after revision hip arthroscopy. Preoperative evaluation with proper radiographs and magnetic resonance arthroscopy (to evaluate labral status, capsule integrity, and capsule extravasation) is critical to planning. My approach, which has evolved or devolved, that I share with patients is that I do not know exactly what will be found, but I will fix it. There is nearly always some unexpected finding. This approach is the reliable, simple idea of restoration of anatomy. This may include removal of suture (especially knots), lysis of capsulolabral adhesions, re-repair of the labrum, labral reconstruction, capsule repair, capsule reconstruction, and femoroplasty (often minor or afterthought). Many of those things are done in the same case. Quite simply, although there are some exceptions, most hips need a labrum and intact ligaments to function properly.
      The concepts have not changed. Restoration of anatomy is our job as surgeons, and we cannot cure arthritis with a scope. Proper evaluation, proper patient selection, and proper execution of the proper surgery are paramount to success. We should continue to publish our clinical results (good and bad) with the hope of continuous improvement. You learn more by failure than you do by success.

      Supplementary Data

      References

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