Speaker 1:
Welcome to the Arthroscopy Journal podcast. I'm Dr. Chris Tucker from TSAOG Orthopedics and Spine in San Antonio, Texas, and the podcast founding editor. Today on the podcast we're discussing labral reconstruction and hip arthroscopy. I'm excited to welcome back to the podcast, the leader in the field of hip arthroscopy, and a friend and former neighbor of mine up from the DC metro area, Dr. Andrew Wolff of Washington Orthopedics and Sports Medicine.
In addition to his busy clinical practice, Dr. Wolff's the vice president of the Multi-Center Arthroscopy Surgery of the Hip Study Group that aggregates data from leading hip surgeons around the country to allow careful research to improve the outcomes for our patients, and in fact was the genesis for the study we're going to be discussing today. Dr. Wolff was the senior author on the paper titled Secondary Hip labral reconstruction Yields Inferior Minimum Two-Year Functional Outcomes to Primary Reconstruction Despite Comparable Interoperative Labral Characteristics, which was recently published in the July 2024 issue of the Arthroscopy Journal. His co-authors include Matthew Yuro, Mark Kurapatti, Dominic Carreira, Shane Nho, and Robroy. Martin. Andy, congrats on yet another really high quality study and welcome back to the podcast.
Speaker 2:
Thanks Chris, and we miss you here in DC and congratulations on starting your new practice out in San Antonio. I know you're going to do great down there with a great group, and thanks again for having me come on. I think this is a good paper that was, I think well done by Matt and Mark were the workhorses on this. There are a couple guys who did years with Dom Carreira in his office and research guys and now are both in medical school and look forward to seeing what they do in the future, but they did a nice job compiling all of this.
Speaker 1:
Yeah, I thought this was a really interesting and exciting study to talk about. So let's start big picture first and share with us your thoughts on the current state of hip arthroscopy with respect to what we're addressing today, its success rates and when it fails. What are the various options and what are the rates of conversion to secondary procedures these days?
Speaker 2:
Well, I think that it depends on what you're looking at, but Alan Zhang recently published a paper showing a two-year subsequent surgery rate up to 19% and 15% of which or 15% of that 19%, it was 15% were scopes and 4% were conversions to total hips. And there've been other studies in the literature showing that that's usually the older folks who get converted to total hip as you might expect. I think that very, very high, but I think it's probably multifactorial and I think more along the lines of people who've been doing it for a while. I think at a high level, you'd be looking more towards a 5% revision rate, but I can certainly attest to that there are a lot of revisions out there because it's probably a good 30 plus percent of my practice, so definitely is out there and I think that is definitely multifactorial.
Speaker 1:
Yeah, so obviously the conversion of total hip is a little bit of a separate topic. Variables like initial indications or pre-existing arthritis likely play a role in that. So I think the indications for converting somebody to total hip with advanced arthritis seems pretty straightforward. But like you said, with such a relatively high revision arthroscopy rate, upwards of 15%, like you said in that one large series, it begs the question why the primary hip scope failed in the first place in the absence of arthritis, and failed at least enough to warrant a second procedure. So can you just review for us briefly, what are the common indications for a revision hip scope?
Speaker 2:
So in the literature, the biggest thing that you'll see historically has been under resection of cam lesions. I would say that from personal experience, yes, that happens, but we also see... And that's an easy problem to fix, and the over resections are a trickier problem to fix. And I think the biggest thing with these is that a lot of times you're not quite sure exactly what the issue is and certainly from a patient's perspective, the approach I take is it's a real pain to have surgery again.
And so my approach is whether I'm seeing them for their first surgery or I'm seeing them for their fifth or 10th surgery, the idea is that we want to make it the last one, and that's the approach I take. And so the literature gets very messy with all of hip arthroscopy for sure, but also in the revision one in particular, you don't know exactly a lot of times even after you do it, what was it? Was it the labral reconstruction you did or was it the revision of the cam or was it the license of adhesions or the repair of the capsule or what have you that was the one thing? Because rarely do I ever go in and just do one thing, so we want to give them the best chance possible. And so it's messy, I would say.
And then add to that the messiness of clinical outcomes research in general, it's hard to really delineate a lot of information. I think we've done a good job in the last 10 to 15 years of delineating often works a lot of the time, and I think it's harder to say what are the things that work just a little bit better? And I think indications do play a huge role, and it's really, really hard to get the experience to really understand some of these weird hip things. And no matter how many fellowships you do and what have you, it's just hard and not everything's straightforward in terms of the various factors that can go into things.
And then of course then there's the whole technical aspect, which is also hard. So that's where I think that the field though, I would say is definitely getting better. And as a whole, everybody's getting better. And we just had the ISHA conference here in DC a couple of weeks ago, and it was people from all over the world and we had really, really great content. And really it's exciting from a scientific perspective to clinical things and the side conversations, "I got this weird thing, what would you do with this?" There's a lot of smart people thinking about it. It is so different than everything else, I think. And so it's interesting to be part of it and to watch it grow over the last 15, 20 years.
Speaker 1:
Yeah, sure. Absolutely. Now, as you highlighted in your article, which obviously we're going to talk about labral reconstruction. So with the prevalence of labral tears being so high, labral reconstruction as an option evolved since it was first used in 2009, and currently there's some evidence that shows comparable outcomes to repair, at least with respect to conversion rates to total hips at three years out. And as you said in your article, despite the increasing evidence to support its success, there's some controversy remaining with respect to the intraoperative indications for when to use it as a tool. Could you just walk us through your thought process on the use of labral recon and what you consider your currently reasonable indications?
Speaker 2:
Yeah, I have probably more expansive indications than the vast, vast majority of people because I think that at least in my hands, I think I see fewer folks come in the three, five-year timeframe with return of hip trouble in the reconstruction patients. And I rarely if ever said, "You know what? I should have just repaired that." Where I'll often think, "I should have reconstructed it when I repaired it." And so I think there is a certain amount of intrasubstance labral damage that we've tried to define across the MASH group, but it's hard.
And so certainly a lot of this labral stuff is sort of in the eye of the beholder, but certainly an ossified labrum or a hypoplastic labrum that's not really giving you a seal, those are good indications for large acetabuli which incorporate the whole labrum and it's loose and you can't take it out without taking out a large chunk of the labrum. And then large pincer lesions where if you take the labrum down, it's just not going to fit. And oftentimes those labra are relatively smaller anyways, and then just geometrically it doesn't fit anymore because you've made that half of a sphere smaller.
And then in my practice, a lot of times we'll see, I'll just look really closely at the MRI and look at intralabral cystic changes or lots of diffuse signal changes in the labrum, particularly in folks who are a little bit older. And that means above 22. I just don't tolerate a lot of it because I just think that they do better if you get the labral reconstruction done. I think they do better. And then I think with the big paralabral cysts, oftentimes those you'll find when you get into the labrum on those that actually it's synovitic inside of it and what have you. And lots of those do just fine if you debris them and then repair what's left over, but sometimes they don't. In my practice, when it's all I do, it only takes a few people who are having trouble to bum out your day and your practice, so you really want to give everybody the best shot.
Speaker 1:
Obviously studying anything can have its challenges, but studying revision hip arthroscopy is particularly challenging for a number of factors and reasons. So I applaud you and your authors for taking that on and developing some methodology that really helped you achieve your goal, which was to compare the outcomes for labral reconstruction in the primary versus revision setting. Can you just go through us now what were your most significant findings?
Speaker 2:
Yeah, so I think when we do these, the way our MASH data is entered in, we say reason for revision. And I almost always check other because I don't really know a lot of times. I have an idea and I have a better idea after we get in there, but in the absence of an anchor in the joint, you don't really know. And so the first thing to think about is the indications in terms of all right, was this ever going to work or did this person need a PAO or a femoral osteotomy or something, or did they need a hip replacement or was this a back problem or something else? And then if it was going to work but it isn't working, then you look and because it is a relatively small field, you say, "All right, well this guy's pretty good. I bet he did a pretty good job."
You look at the pictures and the X-rays before and after and you say, "That looks pretty good. That looks pretty good." And that's why I have a high index of suspicion for the labrum being a big culprit in a lot of these. And it's really hard to interpret the labrum just based on MRI and certainly on MRI reports are all over the board after they've had surgery before. And so I tend to tell patients, "When we're getting an MRI or looking to see a lot of times what it's not as opposed to what it is, so we want to know it's not AVN or it's not arthritis that we can't see on an X-ray or what have you." And so yeah, it's definitely a mixed bag, but I think scar tissue is definitely a big factor in some folks. And then obviously there's the bony aspect that's fairly straightforward. And then the labrum is the other aspect that I think plays a large role.
Speaker 1:
So I took away from your paper you had 77 patients in your final analysis with that minimum two year outcomes, 50 in the primary hip scope group you had 27 revisions. The age was primarily older at 47 and a half years versus 39 years. But interesting to note, you had no difference in the radiographic parameters. Probably more interesting was that even though there was no difference, the revision group had on average, an alpha angle is 65 degrees. So it kind of brings us back to the main indication you said, "Yeah, commonly it's an under resection of the cam or a missed cam." And it's like, "Yeah, if their average alpha angle is 65, clearly there's an underlying under treatment option going on there." That being said, you found no real difference in the intraoperative labral characteristics and no difference in the patient reported outcome measures. Can you just comment a little bit more on those findings that you had in your study? You're obviously the senior author seeing this from a bigger fifty-thousand foot view. What takeaways were you seeing?
Speaker 2:
Yeah, no, I think the characteristics that you point out are interesting. I think the primary reconstructions being older tracks because the vast majority of these patients were my patients and I have a higher propensity to do a reconstruction in the older folks in a primary setting. And then with respect to the alpha angle thing, I think there's definitely a lot of inter and intra observer unreliability with that measurement, but it certainly does point to that tracking with the rest of the literature showing that every section of the cam is a common indication. And I think it's also in part because it is one of the fewer objective things that we can actually report on. We can say, "This is a number and we want it to be 50." But there's alpha angles of 60 that are worse actors than others.
And so I think part of it is to sometimes they do a good job of the cam resection, folks do a good job of the cam section, but it's a little bit too far down the neck and they're still getting impingement. They still have impingement that's more proximal and that is obviously reflected in the alpha angle. And I think also the other thing that I think is different than historical is I think there are more superior based cam legions that we used to leave on address or under addressed and more superior and proximal ones that I think can cause trouble. You obviously have to be careful when you're getting back there with the vessels, but typically the vessels are not involved in and it's more beyond where the vessels go into the head. But those things can definitely play a role in terms of creating problems.
And then of course the labral characteristics are again sort of subjective based on this, what the surgeon's looking at. And we have them graded from no complexity of tear to mild to moderate to severe. And so a lot of the primary ones are going to be in that severe category right away. And then a lot of the repair ones, that labrum looks pretty bad when you get in there and you say, "Well, that's pretty severe." But it is a little bit more of a sort of vibes based thing when you're looking at it.
Speaker 1:
One finding that I found really interesting that I want to discuss just a little bit further was the change in the pre to post op iHOT-12 scores for the primary versus the secondary reconstruction groups. You reported both cohorts experienced significant improvement in their scores, but the final scores for the secondary reconstruction group were inferior to the primary on the order of average, roughly 60 versus 75 on a hundred point scale. So as I usually say, and it's probably not proper English, but both groups got better, but the primary reconstruction group got more better. So I know it's a bit of a nuanced question and there's a grab bag of reasons, but why do you think that is? Did you glean any trends or substantial takeaways during this study that could help maybe answer that?
Speaker 2:
You'll see this across literature, across the hip, arthroscopy literature, the various problems. For instance, even obesity, you say, "All right, these patients..." A couple different papers that been published that say, "These patients do just as well." Well, they don't always do just as well and that from experience, but they get better. And it's where you define better and more better. So you're saying, "All right, 60 versus 75, that's different on an iHOT outcome score." But they start lower and they end lower, but they still get better. Now we also found that on the revision side that fewer of them met MCID and pass, which I think speaks a lot to the fact that your best chance is your first chance, and so your best chance of having really good outcome is the first time.
And I think that's again, multifactorial, assuming that these were, well-indicated surgeries, but something went wrong either with surgery or the rehab or what have you, because that will be the other thing that I will see probably most common indication in my practice is people who just had either they pushed themselves too hard too fast or the therapist pushed them too hard too fast and they just never really slowed down enough to get better before they jumped back into stuff and then they got worse and then they end up try and rehab, rehab, rehab and all sorts of everything, and then you end up re-scoping them.
But in the revision setting, they've already had more persistent pain and dysfunction for a longer period of time, and it's just a much bigger hole to climb out of because they're worse and they're worse for longer. And we also know from the literature that even in a primary setting, patients who have had worse pain and patients who have had a longer duration of pain don't end up doing quite as well. And then you add into that the fact that they had a surgery where they just never got better or they got better and then they got worse again. I think it's just a lot to go through from just a hip trauma standpoint, but also the loss of neuromuscular control and strength and function and motion and what have you. It's just harder to get back. So you get better, but your best shot is your first shot.
Speaker 1:
Yeah, sure. And I know in the past you and I have previously discussed your approach to patients with labral pathology even after index surgery, and as you said earlier, I think you're probably on the end of the spectrum more likely to perform a primary labral recon versus not. But I wanted to know if the results of this study changed any of your thoughts on that or just affirmed your current practice, and maybe more importantly I should say, what practice implications do you think other surgeons who perform hip arthroscopy should take away from your findings from this study?
Speaker 2:
It's hard to say this and it sounds self-serving, but I think if you're not doing a lot of it, you probably shouldn't do any of it in terms of hip arthroscopy in today's day and age because the field has gotten so much better and I think the standard of care is higher, frankly. And so tricky thing to learn, and it's a tricky thing to figure out these patients from a clinical decision-making standpoint. And then also the technical aspect is obviously huge as well as is the rehab aspect. And the flip side of that is of course there are plenty of surgeries that you look at and you're like, "That really wasn't well done." And patient's doing fine, they love it. They'll come in for the side that looks better. The first side they had done looks terrible, but they love it.
And so it's just a tricky thing and I think our outcome measures are also not the greatest in the world either in terms of being able to distinguish between somebody who's doing pretty darn well and somebody who's doing better. The iHOT-12 has been validated upside down and backwards, but if you look at the 12 questions, some of them aren't really super applicable to things that are super important to your patients.
And so I think we have some growth to do in that in terms of that as a field in terms of trying to distinguish what are the things that work just a little bit better than other things? The literature's full of stuff that's like, "All right, this works and this also works just about as well." And I think we're a little bit as a field asking for trouble in that because you get these big registry-type data things where you got all comers and people who do five a year to people who do 400 a year and they're all lumped together with our outcome measures and the bias that's inherent in who fills out their forms and who doesn't and form which patients those surgeons are likely to submit to these registry-type of things.
You're going to end up with a lot of messy data that show, all right, well we can de-breed all labrums and that's cheap, that's easy. There's a low barrier to entry for sure on that in terms of from a surgeon perspective. But as you know, doing a ton of hip arthroscopy yourself, those patients don't do as well. But when it shows no difference, what is the insurance company going to want to pay for 10 acres and a graft and three hours of surgery? They want to pay for 30 minutes of in and out, no bone work, clean it up and get out of dodge. And some of those patients will do great forever. We know from Bird's 10 or twelve-year outcome study from a number of years ago where he looked at the ones from early on in his practice and lots of them were doing fine, but we know lots of them don't do fine. So I think that's the big picture in terms of the way I see it where we need to go as a field for sure.
Speaker 1:
Yeah, that's some great insights and thoughts, just now like you said, big picture for us as a group, as a profession of hip arthroscopists, where do we go from here? I think you've shared a lot of interesting thoughts with us. Any other closing in your remarks you wanted to share before we close out?
Speaker 2:
No. Matt and Mark did a really nice job putting this together and they're definitely to be commended on that and my other co-authors, Rob Martin who is a stats wizard and Shane and Dom contributed cases and ideas and what have you. So I think it was definitely meaningful and it tracks with the way I think about this as your first shot's your best shot. So I think we all, myself included, want to strive to do it right the first time and so that we're not putting people through more surgery than they need for sure.
Speaker 1:
Yeah, and I think, like you said, the first shot's your best shot, but if you do encounter patients who are in this scenario as you encounter many who get sent to you for consideration of a revision, I liked to your comment earlier about how you tell them how you want, be thorough about your workup and your thought process to make sure that whatever it is you do next, if it is surgery, it's their last surgery, which obviously we can't guarantee everybody that, and there is a failure rate and there's a conversion rate. But I think with thoughtful consideration of answering the why, why is this patient sitting in front of me right now after having a previous scope? And being methodical and meticulous about your workup, technically proficient with doing their revision, I think you do a nice job of ensuring that they have the best chance of success the second time around and not just getting whittled on every time they go back to the OR every year or two.
Speaker 2:
Yeah, no, I think that's right. And I think that's probably the thing we want to keep striving for and just keep getting better. And I think we are actually. I think the field is doing really, really well and I think people are just getting better at this overall and just the level of play is so much higher than it was even five or 10 years ago. So it's exciting to see, I would say. But we still got a ways to go, obviously.
Speaker 1:
Yeah, absolutely. And I think the data supporting that, including studies like yours, so congrats again, Andy to you and all your co-authors on this work and all the other stuff you're doing both in the past and what I'm sure you'll continue to do. So thanks for taking the time and sharing your thoughts with us again today.
Speaker 2:
All right, thank you Chris. Really appreciate it.
Speaker 1:
Dr. Wolff's study titled Secondary Hip Labral Reconstruction Yields Inferior Minimum Two-Year Functional Outcomes to Primary Reconstruction Despite Comparable Intraoperative Labral Characteristics is currently available in the July 2024 issue of the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org. This concludes this edition of the Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal. Thank you for listening. Please join us again next time.
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