Speaker 1: Welcome to the Arthroscopy Association of North America's Arthroscopy Journal Podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association of North America or the Arthroscopy Journal.
Dr. Clay Nuelle: Welcome everyone. I'm Dr. Clay Nuelle with TSAOG Orthopedics in San Antonio. Today I have the privilege of speaking with Dr. David Maldonado. Dr. Maldonado is with the American Hip Institute in Chicago, and was the author on a paper entitled Hip Arthroplasty After Hip Arthroscopy: Are Short-term Outcomes Affected? A Systematic Review of the Literature. Dr. Maldonado, thank you for joining me today.
Dr. Maldonado: Thank you Clayton, thank you for the opportunity. First of all, I want to acknowledge all the team that helped me to put this paper together Dr Rosinsky, Kyin, Shapira, Lall, and of course, Dr. Benjamin Domb, as well.
Dr. Clay Nuelle: Awesome. Yeah, that's a great team. Can you start, for those readers and listeners that maybe haven't read the article yet, just to start with a short summary of the findings and the key take home points from you and your coauthors?
Dr. Maldonado: Yeah, so if you review the literature, there is some studies saying that it doesn't matter if you do a hip scope before, or the hip scope will not affect your outcomes if you then perform arthroplasty in that patient. And then, you have another papers that says that it will affect the outcome. So basically, wanted to show and pull all the data together, to see what is the real answer behind that. We previously published a study, maybe two years ago, and we found that there is some findings when you perform hip arthroscopy, and then you have to perform the same patient, and you have to convert him to a total hip arthroplasty we found that the outcomes are not that better. So, and this is in my review, we found when we pull up the data, that actually, the results or the outcomes at medium and short term follow-up are pretty much the same. So that's the main finding of this study.
Dr. Clay Nuelle: Yeah, it's an interesting finding because it's certainly something that I think people discuss as a possible concern when in consideration for doing a hip arthroscopy. There is a slightly increased finding of infection and dislocation rates in the patient populations that had a prior hip scope. It was not statistically significant, but there was a slight increased risk. Do you think that that is possibly a real factor or something that is a real consideration?
Dr. Maldonado: Well, I think so. With this systematic review, we wanted to answer two different questions. The first one is obviously the outcomes and then the complications. The thing is that the data available is not so much. So because of that we didn't have the chance to answer that last question about complications, so in the future I think we're going to need more studies probably a multicenter study with more power so we can answer that question very well, but just to be aware there is a trending and maybe a red flag or a yellow flag. We should be aware about it.
Dr. Clay Nuelle: For sure. Do you think it might change the arthroplasty surgeons approach just knowing that that information is out there, that it's a possibility? For instance, would they maybe change their approach if they're posterior approach surgeon to doing an anterior approach for a total hip or something like that to try and minimize dislocation rate after an arthroscopy procedure? Or do you think it doesn't really matter?
Dr. Maldonado: I don't know. To be honest with you, I don't think this article will answer that. I don't think you have to change the way you approach total hip arthroplasty based just on the fact that you have a previous scope. I don't think that's the point of this paper. But I would like to say that if you review these paper, we can see that patient population is around 50 years old. So this is not the typical hip preservation population that we deal with. So we have to be very cautious about how we analyze this paper. There are some concerns about thinking maybe that are we pushing the limits of indications in these patient population? I think we have to be aware of it. I don't think, I don't want to give us, the people who are listening to us that belief that the message is, if they were so far the same after hip arthroscopy, well let's do a hip scope in these patient populations, cause it doesn't matter. I don't think that's the message. I think we need to be very careful with all indications in this patient population we need to be just as careful [inaudible 00:05:11] patient as well.
Dr. Clay Nuelle: Yeah, that's a great point. That was actually going to be my next question. You know, so you have a patient 50 to 55 years old. Some just are very early degenerative changes. Obviously labeled tearing. Are you going to be more inclined or less inclined potentially to do a scope of that patient's hip? You know, prior to probably knowing that they may progress to an arthroplasty in a few years based on this study or other studies? Or does it not change your approach to that at all?
Dr. Maldonado: Well, I think this study will not answer that, cause we don't know what's the previous arthritis status on these patients. So we cannot answer that. What I can say to you is we have to be aware of this data and I don't know if we can call a hip person patient procedure a success if we're going to convert to a total hip replacement two years after they need a procedure so the ideal site situation will be for that hip to last forever or at least several years and I don't think two years is a way to go. So we have to be careful with this operation. Age itself, I don't think it's a contraindication for a hip scope, but I think the age will tell you that you need to be aware that some arthritic change may be there. Some of this arthritic change, you cannot see it on the x-rays and maybe take care of the MRI. And maybe using the MRIs will be another option to try to see how much cartilage damage is there.
Dr. Clay Nuelle: Yeah, that makes sense. Those are good examples. You guys are obviously a very busy hip arthroscopy practice and get many, many referrals and a lot of different types of patients to you there in Chicago. Are there specific kind of hard set contraindications that you see? You know say you get like the 50 year old or even a little bit younger active patient that comes in where you say, no, we know you're going to progress through an arthroplasty. We don't think an arthroscopy is going to be a benefit to you. Are there specific things that you specifically look for with those types of patients based on this data and your other data?
Dr. Maldonado: Well I think obviously x-rays is the first thing that you see, so if you see any patient with two or more contraindications to proceed with the scope and then we use a lot with MRI and then grade patients that we don't know if we can do a hip scope or not found that maybe we can add some valuable information to make the decision or the best decision.
Dr. Clay Nuelle: That's great. Those are great points. So did this information, or did the study result, did it surprise you at all or it was pretty much exactly what you guys expected and kind of doesn't really change your practice or has it changed the scope of your practice for you and your coauthors at all?
Dr. Maldonado: Well, to be honest with you, it did surprise me because as I said before, we did a study previously a matched controlled study and we found some difference favoring the conditions without the scope prior to that replacement. So as you can see in our hypothesis, we were expecting to see a worse PROs in patients with the previous scopes. So yeah, it did surprise us. But again, we pulled a lot of data here and I am glad. I do believe that the result here was more valued or generalizable that you are privileged to study.
Dr. Clay Nuelle: Yeah, that's very helpful I think. Do you think that the duration of the outcomes would change it? You know, this is relatively short term outcomes. You think if it was mid or even longterm outcomes that it might be different and the results might be different?
Dr. Maldonado: I don't know, that's a good question. And actually that's I think another stat that we need to follow cause we need to know what is the main stations of the hip scope and the short, mid term, and actually long term as well. So that's the future is going there. To the rest those questions?
Dr. Clay Nuelle: Yeah, absolutely. I mean I think in terms of hip arthroscopy, or certainly as people become more facile with the hip scope and more technically better at it just overall, I think the indications have expanded, you know, certainly in the last decade or so. Some of these studies like this kind of seeing, you know, how it extrapolates out and how it comes out. The long term outcomes as the indications get expanded just for the type of patient, like we mentioned earlier, maybe that 50 year old with very early degenerative changes, how things kind of go forward and how it gets expanded for longterm outcomes will be interesting to follow. And certainly your group is a big part of that.
Dr. Maldonado: Yeah, you are totally correct and you know indication is everything in surgery regarding what surgery you are doing. Indication is the first thing deal with.
Dr. Clay Nuelle: Absolutely. Well, thank you for your time today, Dr. Maldonado. Dr. Maldonado's paper, Hip Arthroplasty After Hip Arthroscopy: Are Short-term Outcomes Affected? A Systematic Review of the Literature can be found in the September, 2019 edition of the Arthroscopy Journal, or online at www.arthroscopyjournal.org. Dr. Maldonado, thank you for joining me today.
Dr. Maldonado: Thank you so much for the opportunity.
Dr. Clay Nuelle: That concludes this edition. Please join us next time for the arthroscopy journal podcast.