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Editorial Commentary: To Scope or Not to Scope: Labral Tears in the Early Arthritic Hip
Editorial Commentary: To Scope or Not to Scope: Labral Tears in the Early Arthritic Hip Brian Dierckman, M.D., and Jessica H. J. Ryu, M.D.
Abstract: As hip arthroscopy is increasingly performed, the indications for surgery still remain unclear. How much arthritis is too much? How do we judge this? At this juncture, we need to better define inclusion and exclusion criteria in our studies, and further studies are needed to shed light on which patients are the best candidates for this procedure.
See related article on page 2353
O
ver the past decade, the prevalence of hip arthroscopy has dramatically increased, although its indications remain unclear. One important patient variable receiving significant attention in the literature is degenerative joint disease. Several studies have found that patients with advanced degenerative changes are more likely to have a poor outcome and be converted to a total hip arthroplasty.1-4 Having said that, there are several studies that show that patients with degenerative changes can still have good to excellent outcomes.5,6 How do we make sense of these conflicting results? The Tönnis classification is the most commonly used system for stratifying hip arthroscopy candidates based on the amount of degenerative changes present. Patients with Tönnis grade 0 and 1 hips have minimal to no degenerative changes and are generally expected to do well; however, patients with Tönnis grade 2 hips have significantly more advanced degenerative changes. Most surgeons would consider these to be mildly arthritic hips, and they may not do as well with hip arthroscopy. Despite this, there are conflicting results regarding outcomes of hip arthroscopy in patients with Tönnis grade 2 changes as stated earlier. With this in mind, we read with great interest the recent study “Influence of Tönnis Grade on Outcomes of Arthroscopic Management of Symptomatic
Van Nuys, California The authors report the following potential conflicts of interest or sources of funding: B.D. is a consultant for Mitek and Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/18614/$36.00 https://doi.org/10.1016/j.arthro.2018.06.001
Femoroacetabular Impingement” by Byrd, Bardowski, and Jones,7 which reports patient outcomes following hip arthroscopy for Tönnis grade 2 hips. This study was a retrospective review of a consecutive series of 100 patients on whom the authors collected prospective outcomes data. We commend Byrd et al. for their effort, clinical skill and knowledge, and significant contribution to the field, but would like to point out that the inclusion and exclusion criteria are not well defined. Because of this, we believe this is a “best-case scenario” article because these surgical patients were hand selected by an expert in our field. What were the preoperative characteristics and symptoms of the patients who were not offered surgery? What were their body mass index, age, and activity level, and did they have night pain or standing/walking pain? What were the magnetic resonance imaging findings? As this study suggests, in a carefully selected cohort of patients with Tönnis grade 2 changes, patients can achieve reasonable outcomes at 2 years. It would be far more informative and beneficial, however, to know which criteria were used to both include and exclude patients. Similar to Byrd et al., Chandrasekaran et al.5 published an article on outcomes of hip arthroscopy in patients with Tönnis grade 2 changes. In that study, Chandrasekaran et al. found that at 2-year follow-up, patients with Tönnis grade 2 changes had a significantly higher rate of conversion to total hip arthroplasty. In addition, those authors noted that they excluded patients with preoperative “night pain, pain with ambulation and painful range of motion of the hip.” This is an important fact to consider because we believe that these symptoms are indicative of more advanced arthritis, akin to meniscus tears in arthritic knees. In our experience, we have treated labral tears in
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 8 (August), 2018: pp 2357-2358
2357
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EDITORIAL COMMENTARY
the setting of early arthritis similar to degenerative meniscus tears in the knee. Arthroscopy for degenerative meniscal tears in the setting of arthritis is controversial and has been published on extensively.8-10 The consensus is that patients with less rest pain, less standing and walking pain, and significant pain with associated mechanical symptoms are better candidates for knee arthroscopy. Future research needs to sort out which variables influence the unpredictable array of outcomes for this subgroup of patients. Another point to consider is how useful the Tönnis classification for surgical treatment of labral tears and femoroacetabular impingement is. Similar to many hip arthroscopists, we believe the Tönnis classification is lacking in many ways and does not fully correlate with the degree of pathologic changes seen in femoroacetabular impingement. Many of these patients have 4- to 5-mm joint spaces with minimal sclerosis, but on arthroscopic evaluation the chondrolabral junction has failed and the cartilage is delaminated. Although it may look like a Tönnis grade 1 hip on radiograph, in reality it will likely fail hip arthroscopy. The reliability of this classification has been studied extensively, and the Tönnis grading system has only poor to fair intra- and interobserver reliability. Our experience parallels this; we have unpublished data looking at the intra- and interobserver reliability of the Tönnis grade compared with magnetic resonance angiography and arthroscopic findings; our findings showed intraobserver reliability to be moderate, whereas the interobserver reliability was only fair. In addition, there was poor to fair correlation with findings on magnetic resonance angiography and arthroscopy. As we noted, this classification system is often used in hip arthroscopy studies; because of the proven poor interobserver reliability, there is poor agreement between these studiesdwe may not be comparing “apples to apples.” Although we do agree that radiographic and magnetic resonance imaging scan changes are clearly an important part of the surgical decision-making process,11 we need to strive for a classification system to better stratify patients’ preoperative surgical candidacy. In summary, the article by Byrd et al. suggests that in carefully selected patients with Tönnis grade 2 changes, good outcomes can be achieved from surgery. The article also sheds light on the absence of an accurate classification system on which to base these decisions. Further studies are needed to better understand the best candidates for this procedure. Just as some patients with a
degenerative meniscus tear in the setting of arthritis can do well, some patients with early hip arthritis can do well with hip arthroscopy, but many of them do not. Our goal should be to better define inclusion and exclusion criteria, whether it is by looking at preoperative range of motion, night pain, rest pain, body mass index, mechanical symptoms, or a variety of other factorsdthe improvement of our outcomes depends on it.
References 1. Ross JR, Larson CM, Bedi A. Indications for hip arthroscopy. Sports Health 2017;9:402-413. 2. Haviv B, O’Donnell J. The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients. Sports Med Arthrosc Rehabil Ther Technol 2010;2:18. 3. Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint space predicts THA after hip arthroscopy in patients 50 years and older. Clin Orthop Relat Res 2013;471:2492-2496. 4. Kemp JL, MacDonald D, Collins NJ, Hatton AL, Crossley KM. Hip arthroscopy in the setting of hip osteoarthritis: Systematic review of outcomes and progression to hip arthroplasty. Clin Orthop Relat Res 2015;473:1055-1073. 5. Chandrasekaran S, Darwish BS, Gui C, Lodhia P, SuarezAhedo C, Domb B. Outcomes of hip arthroscopy in patients with Tonnis grade-2 osteoarthritis at a mean 2 year follow up: Evaluation using a matched-pair analysis with Tonnis grade 0 and grade 1 cohorts. J Bone Joint Surge Am 2016;98:973-982. 6. Sansone M, Ahlden M, Jonasson P, et al. Outcome of hip arthroscopy in patients with mild to moderate osteoarthritisdA prospective study. J Hip Preserv Surg 2016;3: 61-67. 7. Byrd JW, Bardowski EA, Jones KS. Influence of Tönnis grade on outcomes of arthroscopic management of symptomatic femoroacetabular impingement. Arthroscopy 2018;34:2353-2356. 8. Buchbinder R. Meniscectomy in patients with knee osteoarthritis and a meniscal tear? N Engl J Med 2013;368: 1740-1741. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88. 10. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675-1684. 11. Krych AJ, King AH, Berardellia R, Sousa PL, Levy BA. Is subchondral acetabular edema or cystic change on MRI a contraindication for hip arthroscopy in patients with femoroacetabular impingement? Am J Sports Med 2016;44: 454-460.
Abstract: As hip arthroscopy is increasingly performed, the indications for surgery still remain unclear. How much arthritis is too much? How do we judge this? At this juncture, we need to better define inclusion and exclusion criteria in our studies, and further studies are needed to shed light on which patients are the best candidates for this procedure.
See related article on page 2353
O
ver the past decade, the prevalence of hip arthroscopy has dramatically increased, although its indications remain unclear. One important patient variable receiving significant attention in the literature is degenerative joint disease. Several studies have found that patients with advanced degenerative changes are more likely to have a poor outcome and be converted to a total hip arthroplasty.1-4 Having said that, there are several studies that show that patients with degenerative changes can still have good to excellent outcomes.5,6 How do we make sense of these conflicting results? The Tönnis classification is the most commonly used system for stratifying hip arthroscopy candidates based on the amount of degenerative changes present. Patients with Tönnis grade 0 and 1 hips have minimal to no degenerative changes and are generally expected to do well; however, patients with Tönnis grade 2 hips have significantly more advanced degenerative changes. Most surgeons would consider these to be mildly arthritic hips, and they may not do as well with hip arthroscopy. Despite this, there are conflicting results regarding outcomes of hip arthroscopy in patients with Tönnis grade 2 changes as stated earlier. With this in mind, we read with great interest the recent study “Influence of Tönnis Grade on Outcomes of Arthroscopic Management of Symptomatic
Van Nuys, California The authors report the following potential conflicts of interest or sources of funding: B.D. is a consultant for Mitek and Arthrex. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/18614/$36.00 https://doi.org/10.1016/j.arthro.2018.06.001
Femoroacetabular Impingement” by Byrd, Bardowski, and Jones,7 which reports patient outcomes following hip arthroscopy for Tönnis grade 2 hips. This study was a retrospective review of a consecutive series of 100 patients on whom the authors collected prospective outcomes data. We commend Byrd et al. for their effort, clinical skill and knowledge, and significant contribution to the field, but would like to point out that the inclusion and exclusion criteria are not well defined. Because of this, we believe this is a “best-case scenario” article because these surgical patients were hand selected by an expert in our field. What were the preoperative characteristics and symptoms of the patients who were not offered surgery? What were their body mass index, age, and activity level, and did they have night pain or standing/walking pain? What were the magnetic resonance imaging findings? As this study suggests, in a carefully selected cohort of patients with Tönnis grade 2 changes, patients can achieve reasonable outcomes at 2 years. It would be far more informative and beneficial, however, to know which criteria were used to both include and exclude patients. Similar to Byrd et al., Chandrasekaran et al.5 published an article on outcomes of hip arthroscopy in patients with Tönnis grade 2 changes. In that study, Chandrasekaran et al. found that at 2-year follow-up, patients with Tönnis grade 2 changes had a significantly higher rate of conversion to total hip arthroplasty. In addition, those authors noted that they excluded patients with preoperative “night pain, pain with ambulation and painful range of motion of the hip.” This is an important fact to consider because we believe that these symptoms are indicative of more advanced arthritis, akin to meniscus tears in arthritic knees. In our experience, we have treated labral tears in
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 8 (August), 2018: pp 2357-2358
2357
2358
EDITORIAL COMMENTARY
the setting of early arthritis similar to degenerative meniscus tears in the knee. Arthroscopy for degenerative meniscal tears in the setting of arthritis is controversial and has been published on extensively.8-10 The consensus is that patients with less rest pain, less standing and walking pain, and significant pain with associated mechanical symptoms are better candidates for knee arthroscopy. Future research needs to sort out which variables influence the unpredictable array of outcomes for this subgroup of patients. Another point to consider is how useful the Tönnis classification for surgical treatment of labral tears and femoroacetabular impingement is. Similar to many hip arthroscopists, we believe the Tönnis classification is lacking in many ways and does not fully correlate with the degree of pathologic changes seen in femoroacetabular impingement. Many of these patients have 4- to 5-mm joint spaces with minimal sclerosis, but on arthroscopic evaluation the chondrolabral junction has failed and the cartilage is delaminated. Although it may look like a Tönnis grade 1 hip on radiograph, in reality it will likely fail hip arthroscopy. The reliability of this classification has been studied extensively, and the Tönnis grading system has only poor to fair intra- and interobserver reliability. Our experience parallels this; we have unpublished data looking at the intra- and interobserver reliability of the Tönnis grade compared with magnetic resonance angiography and arthroscopic findings; our findings showed intraobserver reliability to be moderate, whereas the interobserver reliability was only fair. In addition, there was poor to fair correlation with findings on magnetic resonance angiography and arthroscopy. As we noted, this classification system is often used in hip arthroscopy studies; because of the proven poor interobserver reliability, there is poor agreement between these studiesdwe may not be comparing “apples to apples.” Although we do agree that radiographic and magnetic resonance imaging scan changes are clearly an important part of the surgical decision-making process,11 we need to strive for a classification system to better stratify patients’ preoperative surgical candidacy. In summary, the article by Byrd et al. suggests that in carefully selected patients with Tönnis grade 2 changes, good outcomes can be achieved from surgery. The article also sheds light on the absence of an accurate classification system on which to base these decisions. Further studies are needed to better understand the best candidates for this procedure. Just as some patients with a
degenerative meniscus tear in the setting of arthritis can do well, some patients with early hip arthritis can do well with hip arthroscopy, but many of them do not. Our goal should be to better define inclusion and exclusion criteria, whether it is by looking at preoperative range of motion, night pain, rest pain, body mass index, mechanical symptoms, or a variety of other factorsdthe improvement of our outcomes depends on it.
References 1. Ross JR, Larson CM, Bedi A. Indications for hip arthroscopy. Sports Health 2017;9:402-413. 2. Haviv B, O’Donnell J. The incidence of total hip arthroplasty after hip arthroscopy in osteoarthritic patients. Sports Med Arthrosc Rehabil Ther Technol 2010;2:18. 3. Philippon MJ, Briggs KK, Carlisle JC, Patterson DC. Joint space predicts THA after hip arthroscopy in patients 50 years and older. Clin Orthop Relat Res 2013;471:2492-2496. 4. Kemp JL, MacDonald D, Collins NJ, Hatton AL, Crossley KM. Hip arthroscopy in the setting of hip osteoarthritis: Systematic review of outcomes and progression to hip arthroplasty. Clin Orthop Relat Res 2015;473:1055-1073. 5. Chandrasekaran S, Darwish BS, Gui C, Lodhia P, SuarezAhedo C, Domb B. Outcomes of hip arthroscopy in patients with Tonnis grade-2 osteoarthritis at a mean 2 year follow up: Evaluation using a matched-pair analysis with Tonnis grade 0 and grade 1 cohorts. J Bone Joint Surge Am 2016;98:973-982. 6. Sansone M, Ahlden M, Jonasson P, et al. Outcome of hip arthroscopy in patients with mild to moderate osteoarthritisdA prospective study. J Hip Preserv Surg 2016;3: 61-67. 7. Byrd JW, Bardowski EA, Jones KS. Influence of Tönnis grade on outcomes of arthroscopic management of symptomatic femoroacetabular impingement. Arthroscopy 2018;34:2353-2356. 8. Buchbinder R. Meniscectomy in patients with knee osteoarthritis and a meniscal tear? N Engl J Med 2013;368: 1740-1741. 9. Moseley JB, O’Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-88. 10. Katz JN, Brophy RH, Chaisson CE, et al. Surgery versus physical therapy for a meniscal tear and osteoarthritis. N Engl J Med 2013;368:1675-1684. 11. Krych AJ, King AH, Berardellia R, Sousa PL, Levy BA. Is subchondral acetabular edema or cystic change on MRI a contraindication for hip arthroscopy in patients with femoroacetabular impingement? Am J Sports Med 2016;44: 454-460.