Binary Tönnis classification: simplified modification demonstrates better inter- and intra-observer reliability as well as agreement in surgical management of hip pathology

Similar Clinical Outcomes for Arthroscopic Labral Reconstruction in Irreparable Cases Using the Indirect Head of the Rectus Femoris Tendon With an All-Inside Technique for Small Defects and the Iliotibial Band for Large Defects

PURPOSE

To evaluate the clinical outcomes and satisfaction rate of patients who underwent arthroscopic labral reconstruction for an irreparable labral tear with a minimum follow-up period of 2 years. Additionally, this study aimed to compare 2 different reconstructive techniques for small and large labral defects: the indirect head of the rectus femoris tendon (IHRFT) autograft with an all-inside technique used to repair small defects (≤3 hours) and the iliotibial band (ITB) autograft for large defects (>3 hours).

METHODS

A total of 24 hips treated with the IHRFT were compared with 24 hips treated with the ITB. All patients underwent clinical evaluation before surgery and during the most recent follow-up (42 ± 18 months). The evaluation included patient satisfaction, the modified Harris Hip Score, the Non-Arthritic Hip Score, the Hip Outcome Score, the Hip Outcome Score-sport subscale, the 12-item International Hip Outcome Tool, and the visual analog scale pain score.

RESULTS

All clinical scores were significantly improved (P < .001) at the latest follow-up in both groups. The final satisfaction was 7.1 ± 2.8 and 8.8 ± 1.6 for the IHRFT and ITB groups, respectively (P = .006). There was a significant difference in age (41.2 ± 6.0 years for the IHRFT group and 33 ± 8.5 for the ITB group; P = .004) and in surgery time (147.3 ± 39.4 minutes for the ITB group and 105.3 ± 25.7 for the IHRFT group; P < .001). One patient (4.2%) in the IHRFT group underwent total hip arthroplasty after 21.3 months (P = .999).

CONCLUSIONS

At the 2-year follow-up, treating small defects using IHRFT and larger defects using ITB resulted in good patient-reported outcome measures with a low rate of complications and failures. The ITB group reported a higher level of satisfaction at the final follow-up.

LEVEL OF EVIDENCE

Level III, retrospective comparative therapeutic trial.

Post-traumatic stress disorder is more likely in younger patients undergoing lower limb arthroplasty: impact on function and quality of life

INTRODUCTION

The aim of this study was to assess whether PTSD was associated with preoperative and/or postoperative joint-specific function and health-related quality of life (HRQoL) in patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) and whether there were associated preoperative factors.

METHODS

A retrospective study was conducted at a single centre using an established arthroplasty database over a 2-year period. Patients undergoing THA and TKA completed pre and 1-year postoperative Oxford hip/knee scores and EuroQoL questionnaire (EQ-5D) to assess joint specific function and HRQoL. Postoperatively, patients completed the self-reported PTSD Checklist for DSM-5 (PCL-5) questionnaire where a score of 31 or greater was used to determine a provisional diagnosis of PTSD.

RESULTS

There were 1244 THA and 1356 TKA patients, of which 42 (3.4%) and 54 (4.0%) had a PCL-5 score of ≥ 31, respectively (PTSD groups). Younger age was associated (p < 0.001) with PTSD for both THA (mean difference (MD) 9.9, 95%CI 6.7-13.0) and TKA (MD 4.6, 95%CI 2.2-6.9), which remained significant when adjusting for confounding variables (THA: p < 0.001; TKA: p = 0.020). The preoperative Oxford (THA:MD 4.9, p < 0.001; TKA:MD 5.7, p < 0.001) and EQ-5D scores (THA:MD 0.378, p < 0.001; TKA:MD 0.276, p < 0.001) were significantly worse in the PTSD groups. Age (AUC 73.8%, p < 0.001) and EQ-5D (AUC 72.9%, p < 0.001) were independent factors that were predictive of PTSD in patients undergoing THA and TKA, respectively. When adjusting for confounding variables, PTSD was clinically and statistically significantly (p < 0.001) associated with a lower improvement in the Oxford (THA:MD 9.3; TKA:MD 10.0) and EQ-5D (THA:MD 0.375; TKA:MD 0.293) scores.

CONCLUSIONS

One in 25 patients met a provisional PTSD diagnosis; they were younger and had worse preoperative and improvement in postoperative joint specific function and HRQoL. Age and EQ-5D could be used to identify patients at risk.

Postoperative alpha angle seems to be important for the achievement of clinical significance at a minimum 5-year follow-up after primary hip arthroscopy

The purpose of the present study was to clarify whether there is an association of postoperative alpha value with functional scores or progression of osteoarthritis at X-rays at the midterm after arthroscopic treatment of femoroacetabular impingement (FAI) syndrome with femoral osteoplasty, labral repair or debridement and rim trimming. A retrospective review of prospectively gathered data from 2013 to 2017 was performed. All patients who underwent first-time unilateral hip arthroscopy for FAI resection with 5-year follow-up were included. Patient-reported outcomes included the modified Harris Hip Score (mHHS) and Visual Analog Scale for Pain (Pain VAS). The progression of osteoarthritis (Tönnis grade) and radiological parameters (alpha angle, lateral center-edge angle [LCEA] and head-neck offset) were evaluated. A receiver operating characteristic (ROC) analysis was used to evaluate the correlation between significant variables and achievement of patient-acceptable symptomatic state (PASS) and degree of osteoarthritis. We identified 52 patients with a minimum 5-year follow-up (average, 6.7 years). The average patient age was 33.9 ± 11.5 years. There were 19 (36.5%) female patients. The mHHS improved from 60.1 ± 13.4 before surgery to 86.8 ± 14 after surgery (P < 0.001). The Pain VAS decreased from 6.21 before surgery to 2 after surgery (P < 0.001). Overall, 69% achieved the PASS for mHHS. The ROC curve for postoperative alpha angle demonstrated acceptable discrimination between patients achieving a fifth-year PASS value and those who did not have an area under the curve of 0.72. Patients having a postoperative alpha angle of ≤48.3° achieved the fifth-year PASS value at a significantly higher rate than patients having a postoperative alpha angle of >48.3° (P = 0.002). The postoperative alpha angle is a predictor of the achievement of the fifth-year PASS value for the mHHS. A threshold of ≤48.3° had a sensitivity of 0.75 and a specificity of 0.69 to predict positivity. Level of evidence IV.

The Reliability of the Tönnis Grading System in Patients Undergoing Hip Preservation

BACKGROUND

The presence of pre-existing osteoarthritis (OA) has been associated with poor results after hip arthroscopic surgery. There is limited evidence validating the currently available grading systems of hip OA in patients undergoing hip preservation.

PURPOSE/HYPOTHESIS

Our purpose was to evaluate the interobserver and intraobserver reliabilities of 2 grading systems in a group of patients undergoing hip preservation: the Tönnis grading system and a simple 4-choice Likert scale. The hypothesis was that interobserver and intraobserver reliabilities using the Tönnis grading system would be poor among surgeons experienced in hip preservation and that a 4-choice Likert scale would be more reliable.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 3.

METHODS

A total of 100 hip radiographs were reviewed by 8 experienced hip preservation surgeons. Overall, 2 rounds of reviews were performed, at least 3 weeks apart, assessing for the presence, degree, and/or location of joint space narrowing, joint space asymmetry, subchondral cysts, osteophytes, and sclerosis. The radiographs were assigned a Tönnis grade as well as a Likert grade of OA, reported as none, mild, moderate, or severe. Statistical analysis was conducted to provide Fleiss kappa values with 95% CIs. Agreement was classified as poor for <0.00, slight for 0.00-0.20, fair for 0.21-0.40, moderate for 0.41-0.60, substantial for 0.61-0.80, and almost perfect for >0.80.

RESULTS

A total of 50 patients (28 female and 22 male) with a mean age of 42.8 ± 14.2 years (range, 19-70 years) were reviewed. The Tönnis grade demonstrated an interobserver kappa value of 0.30 (95% CI, 0.26-0.34). The Likert grade demonstrated an interobserver kappa value of 0.33 (95% CI, 0.28-0.37). All other measures demonstrated interobserver kappa values classified as slight or fair except for subchondral cysts which was moderate. Intraobserver reliabilities were statistically significantly higher than interobserver reliabilities. Intraobserver reliabilities for both the Tönnis grade (κ = 0.55 [95% CI, 0.51-0.60]) and Likert grade (κ = 0.59 [95% CI, 0.55-0.63]) demonstrated similar kappa values, consistent with moderate agreement. Subchondral cysts demonstrated the strongest interobserver (κ = 0.53) and intraobserver (κ = 0.85) reliabilities.

CONCLUSION

Interobserver and intraobserver reliabilities were fair and moderate, respectively, for grading OA. Given the limited interobserver reliability, caution should be used when interpreting and translating studies that utilize the Tönnis grade or other rating to dictate treatment algorithms.

Outcomes of Staged Bilateral Hip Arthroscopic Surgery in the Context of Femoroacetabular Impingement Syndrome: A Nested Matched-Pair Control Study Focusing on the Effect of Time Between Procedures

BACKGROUND

Bilateral hip symptoms from femoroacetabular impingement syndrome (FAIS) are a common finding in patients regardless of athletic involvement. Oftentimes, patients and surgeons choose to stage bilateral hip arthroscopic surgery.

PURPOSE/HYPOTHESIS

The purpose of this study was (1) to compare minimum 2-year outcomes between patients who underwent staged bilateral hip arthroscopic surgery for FAIS to a propensity score-matched control group that underwent unilateral hip arthroscopic surgery and (2) to investigate the effect of time between bilateral procedures on patient-reported outcomes (PROs). We hypothesized that, after bilateral hip arthroscopic surgery, the improvement in outcomes would be similar to that after unilateral hip arthroscopic surgery and the time duration between bilateral procedures would not affect the final outcome.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Data were retrospectively reviewed on a consecutive series of patients who underwent primary hip arthroscopic surgery at our institution between June 2008 and November 2017. Patients who underwent bilateral hip arthroscopic surgery with minimum 2-year PROs for the modified Harris Hip Score (mHHS), the Nonarthritic Hip Score (NAHS), the Hip Outcome Score-Sports Specific Subscale (HOS-SSS), patient satisfaction, and a visual analog scale (VAS) for pain were included. The study group was matched 1:1 based on age, sex, and body mass index to a control group that only required unilateral hip arthroscopic surgery. Additionally, a subanalysis was performed on the study group to determine the effect of time between arthroscopic procedures. Rates of achieving the minimal clinically important difference (MCID) and Patient Acceptable Symptom State (PASS) for the mHHS and HOS-SSS were determined. The P value was set at <.05.

RESULTS

A total of 205 patients (410 hips) were included. The mean age and body mass index of the study group were 32.3 ± 13.2 years and 25.0 ± 5.1, respectively. All 410 hips that met the inclusion criteria were matched. There were no significant differences in patient, radiographic, or procedural data. A significant and comparable improvement was reported for all PRO measures and the VAS (P < .0001) in both groups. Similarly, rates of achieving the MCID and PASS were comparable. After dividing the study group based on whether the contralateral procedure was performed <3 months or >3 months after the first procedure, it was determined that patients had a significant improvement and favorable outcomes regardless of time between bilateral procedures.

CONCLUSION

Patients who underwent unilateral and bilateral hip arthroscopic surgery for FAIS had a significant and comparable improvement in PROs at a minimum 2-year follow-up. A time interval of <3 months or >3 months between bilateral procedures did not affect PROs.

Femoro-Epiphyseal Acetabular Roof (FEAR) Index and Anterior Acetabular Coverage Correlate With Labral Length in Developmental Dysplasia of the Hip

PURPOSE

The aim of this study was to evaluate the association between labral length and radiographic parameters of lateral and anterior acetabular coverage and the femoro-epiphyseal acetabular roof (FEAR) index in patients with developmental dysplasia of the hip (DDH).

METHODS

We retrospectively analyzed data from patients with DDH who visited our hip joint clinic for the first time due to hip symptoms. DDH presence was defined as a lateral center-edge angle (LCEA) of ≤25°. The labral lengths on the anterior and lateral sides were measured on central axial and central coronal slices of T1-weighted magnetic resonance imaging, respectively. The Pearson correlation coefficients (r) and simple linear regression analyses were performed to determine the association of the lateral and anterior labral lengths with the radiographic parameters, including the LCEA, acetabular roof obliquity, FEAR index, anterior wall index, and vertical center anterior angle.

RESULTS

This study included 88 patients, with a mean age of 39.6 ± 11.8 years. There were 65 women and 23 men. The lateral and anterior labral lengths correlated with all parameters of dysplasia. Specifically, the lateral labral length had a strong positive correlation with the FEAR index (R = 0.65, P < .001). The anterior labral length had a strong negative correlation with the anterior wall index (R = -0.66, P < .001).

CONCLUSIONS

The lateral labral length had a strong positive correlation with the FEAR index. Furthermore, the anterior labral length had a correlation with the anterior dysplasia.

LEVEL OF EVIDENCE

Level III, retrospective cross-sectional study.