Dr. Clayton Nue...: 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. Clayton Nue...: Welcome everyone. I'm Dr. Clayton Nuelle with TSAOG Orthopedics in San Antonio. Today, I have the privilege of speaking with Dr. Austin Chen. Dr. Chen is a hip preservation specialist at Boulder Center for Orthopedics in Colorado and was the primary author on a paper entitled Return to Basketball After Hip Arthroscopy: Minimum Two Year Follow Up, which was published in the October, 2019 edition of the Arthroscopy Journal.
Dr. Clayton Nue...: Austin, thank you for joining me today.
Dr. Austin Chen: Clayton, thank you very much for the invitation.
Dr. Clayton Nue...: Let's start by just going over maybe a little bit of the impetus and background for the study and then maybe one or two of the main conclusions that you and your coauthors would like our listeners to take away from it.
Dr. Austin Chen: Yeah, absolutely. Basketball was considered a high risk sport for failing to return to sport and at the American Hip Institute where I did my fellowship, they have a large prospectively collected but retrospectively reviewed database of patients who are able to keep track of their specific sports so we selected them out and provided exclusion criteria and ran study that way.
Dr. Austin Chen: And the results were somewhat as expected but somewhat surprising. Expected in the fact that return to sport rate was around 84%, which is between the 80-90 percentile where most people are returning to sport after hip arthroscopy.
Dr. Austin Chen: And the surprising part was the number of patients, or I guess I should say the patients that were having total hip arthroplasty, were on the younger side of things and all of those patients were over 40 years old.
Dr. Clayton Nue...: Yeah, it was interesting. I think the numbers were 9.7 or almost 10% went on to a conversion to a total hip arthroplasty at an average age of 47.5 years. And so, do you think that is just a factor of this particular cohort? As you mentioned, at the American Hip Institute you guys do a lot of hip scopes and see a wide range of hip pathology and so is it strictly a matter of age or a matter of maybe stretching the indications for a hip scope in some of those patients? Or are there other factors at play, do you think?
Dr. Austin Chen: I think there's a number of factors involved here. First, being that the majority of patients were male, approximately two thirds, close to two thirds, 65%. Males tend to have larger cam deformities, which has been correlated with more cartilage damage so despite polluting out patients graded tonus two and higher at the time of arthroscopy, 46% had grade three or higher ALAD lesions and 40% had grade three or higher outerbridge classification on the acetabular side of the joint.
Dr. Austin Chen: The other factor being that basketball is a very challenging sport on your joints. A lot of hard stops, start, cutting, pivoting, twisting, and on a pre-arthritic or early arthritic joint, that's a difficult sport to return to.
Dr. Clayton Nue...: Absolutely. I think that's a great point. That was actually going to be one of my questions. Do you think that some of the results might differ and you guys I think in published some data on some different sports, I think soccer being one of them, maybe even football as well. Do you think that some of these results after hip arthroscopy might differ for other sports or maybe in particular, for sports that requires significant repetitive hip flection such as rowing or gymnastics? Or do you think by doing the hip arthroscopy, taking care of the cam or the combined cam and pincer lesions and that sort of thing, that doesn't matter which sport it is, even if they require repetitive hip flection or impact, does it matter? What do you think in regards to other sports and if it's generalizable?
Dr. Austin Chen: So we touched on a lot of things there. I think number one, age probably comes into this. Like I said, the larger the cam, probably the higher, or excuse me, the more cartilage damage you have. So if you get somebody on the younger side of things, as you saw all five of the high school athletes returned to play, I think the cartilage damage is probably less. And the results ... it's probably better in that cohort.
Dr. Austin Chen: I don't think it's just the flection. Rowing may involve a lot of hip flection, but it's all linear. Whereas basketball and walking involves a lot of that internal external rotation when making moves and I think that's when patients have difficulty returning to sport.
Dr. Austin Chen: Gymnastics typically, in most gymnastics patients that we've seen or that I've seen and treated, are typically female that have a combination of generalized ligamentous laxity, maybe some borderline dysplasia. And even though their results may parallel basketball and that's a difficult sport to return to, I think they're probably having a difficult time returning for different reasons.
Dr. Clayton Nue...: Yeah, that makes sense. What about level of competition? So in this study, about 55% of athletes identified themselves as recreational athletes. So you know, that's kind of like the general weekend warrior for the most part probably. But do you think the results generalizable or would be applicable at the collegiate or even professional level or is that a whole different level of impact and strength and activity requirements that may potentially change the data?
Dr. Austin Chen: So I think there we get more into the problems with return to sports study and the motivations to return to sport where you're relying on that sport as a livelihood or a potential livelihood. Whereas you know, weekend warrior recreational athletes are more apt to give that up. So I'm not exactly sure that's a hip or hip arthroscopy specific issue.
Dr. Clayton Nue...: Yeah, definitely. You made a great point about return to sports studies in general and I think it's always interesting to compare some of these studies like this that include recreational athletes versus some of like the studies in say like the NFL database or the major league baseball databases that are primarily strictly minor league or professional athletes because I think they are definitely different patient populations, but certainly we all treat a variety of those across different levels of competition and patient population so it's useful information to have across each of those populations.
Dr. Clayton Nue...: So this was a relatively short term minimum two year follow up study. Do you think these results change at all if you take it out to mid and longterm followup? And if so, how?
Dr. Austin Chen: I do and that parallels most of the research and literature on hip arthroscopy in general and that we've noticed our results slowly declining, but maintaining a statistical significant improvement over time.
Dr. Austin Chen: I can bring up a running, a return to running after hip arthroscopy. There was a two year study published out of [Rush] that's a 90 plus percent return to sport. And then we published a five year return to running paper that show that return to sport percentage dropped into the low 80s, upper 70s, so just three years later.
Dr. Austin Chen: And with the 10% conversion to total hip, younger patients, I would expect the results of this or excuse me, not the results, the return to sport rates to decline over time.
Dr. Clayton Nue...: Yeah, it definitely makes sense. I mean, certainly it's like anything we do in orthopedics, nothing changes terrific results like longterm followup, but certainly, like as you mentioned before, when you're talking about high impact sports and high impact activities, you kind of always wonder what the longterm, not only return to sport but then longevity of that return to play or that return to sport is.
Dr. Clayton Nue...: And so, did the results of this particular study, did they change the way you or your coauthors practice or approach basketball playing patients or just athletes of this type of level in particular?
Dr. Austin Chen: It's certainly impacted how I'm at least educating and talking to patients. If I see a middle aged male that is interested in basketball and a candidate for hip arthroscopy, I'll be very, very frank and tell him that that's probably not in his hips best interests, basketball that is, to continue doing that after surgery. And I'll emphasize lower impact linear types of activities and if that's something that they are okay modifying and changing in their life, then I think hip arthroscopy has a good chance of it improving their quality of life and their level of function.
Dr. Austin Chen: But if they want to return to basketball, they just have to know that it's probably one of the higher sports to return to and they possibly are at a higher risk of getting a hip replacement at a younger age.
Dr. Clayton Nue...: So when you say middle age, are you setting that defined age limit, like say age 40 or is it a general mid age range?
Dr. Austin Chen: I use 40 as kind of the bar. However, I'll use imaging and patient specifics to dictate how that conversation goes. I mean, if I see someone in their late 30s who already has tonus one changes, I'll have that same conversation.
Dr. Austin Chen: However, if I see somebody's nearly 50 who maybe plays one game of basketball a week and their cam is on the smaller side and there's not really any evidence of pre-arthritic or early arthritic changes, then I may be less apt to have that conversation with them or at least less apt to emphasize it.
Dr. Clayton Nue...: That's terrific. Yeah, those are perfect pointers. I gave up basketball after age 35 so hopefully my hips are good for at least a while and you don't have to replace them for me.
Dr. Clayton Nue...: All right. Well, that's terrific information. Austin, thank you very much for joining me today.
Dr. Austin Chen: Clayton, thank you again. I appreciate it.
Dr. Clayton Nue...: Dr. Austin Chen's article Return to Basketball After Hip Arthroscopy: Minimum Two Year Follow Up can be found in the October, 2019 edition of the Arthroscopy Journal or online www.arthroscopyjournal.org.
Dr. Clayton Nue...: That concludes this edition of the Arthroscopy Journal podcast. Thank you for listening. If you enjoy the podcast, please remember to give us a five star review on your podcast device.