Patients who experience persistent hip pain after nonoperative treatments for partial or full-thickness gluteus medius tears have two surgical repair options: open or endoscopic. A two-year follow up study by Chandrasekaran et al. in the August 19, 2015 edition of The Journal of Bone & Joint Surgery found that endoscopic repair with correction of identified intra-articular pathology yielded substantial postprocedure functional improvements and pain reduction, along with high levels of overall patient satisfaction. In addition, 15 of the 26 patients who had preoperative gait deviations were found to have a completely normal gait at the two-year follow up. No postoperative complications or re-tears were reported.
The study followed 34 patients (predominantly women, mean age of 57 years) who had endoscopic repairs. Seventeen (50%) of the patients with full-thickness or near full-thickness tears were treated with a suture bridge technique, while the 17 with partial-thickness tears received a transtendinous repair. There was no significant difference in patient-reported outcome measures between the two surgical techniques.
The ability to address intra-articular pathology is touted as an advantage of the endoscopic approach, and in this study concomitant procedures included capsule release, labral debridement and repair, and acetabuloplasty.
Although the Chandrasekaran et al. study did not compare outcomes of endoscopic versus open repair, it did track the largest reported number of endoscopy patients for the longest reported duration.
The April 1, 2015 JBJS features a level II prognostic study that analyzes registry data from 243 patients (mean age: 29) who underwent arthroscopic surgery to correct femoroacetabular impingement (FAI). Almost everyone experienced clinically important and statistically significant post-arthroscopy improvements in patient-reported outcomes. However, those with relative femoral retroversion (<5° anteversion) prior to surgery experienced smaller magnitudes of improvement than those with normal or increased femoral version.
Researchers found no association between the participants’ McKibbin index (calculated from both femoral and acetabular version) and patient-reported outcomes.
According to the authors and to commentator Keith Baumgarten, MD, these results indicate that surgeons should not consider femoral retroversion to be an absolute contraindication to arthroscopic correction of FAI. However, while the findings may help orthopaedists offer prognostic counseling to young and middle-aged adults who are considering arthroscopy for FAI, the authors say the findings “may not be externally valid in adolescents,” who represent a substantial percentage of patients diagnosed with this hip condition.
A review of five hip- and knee-implant innovations, initiated by the FDA in reaction to serious problems with metal-on-metal hip bearings, found that none offered meaningful functional or patient-outcome benefits over older designs. The systematic review of 118 studies and more than 13,000 patients, published in the BMJ, also found that three of the new designs—ceramic-on-ceramic hip bearings, modular femoral necks, and high-flexion knee implants—were associated with higher revision rates relative to established designs. The other two innovations—uncemented monoblock acetabular cups and sex-specific knee implants—provided no benefit over older designs but had comparable revision rates.
The BMJ authors claim that the purpose of the review was not to “criticise the surgical community or orthopaedic industry,” but rather to “highlight that the status quo regarding the introduction of new device technologies is not acceptable.”
The BMJ authors cite stepwise introduction of new implant technologies as one way to avoid exposing large numbers of patients to innovations whose safety and efficacy are unproven. In a 2011 JBJS supplement, authors (two of whom also co-authored the BMJ study) proposed using roentgen stereophotogrammetric analysis (RSA) and national joint registry data to facilitate phased clinical introduction of new implants.
UK epidemiologists presenting at the annual meeting of the British Society for Rheumatology recently reported that X-ray evidence of rapid rheumatoid arthritis (RA) progression during the first 12 months of the disease can help predict the need for later surgery of hand, foot, hip, and knee joints. Lewis Carpenter and colleagues analyzed data from the Early Rheumatoid Arthritis Study and found that a change in the Larsen radiographic score of four units during the first 12 months of RA was associated with an 80% increased risk of subsequent surgery on joints of the hand and foot, and a 50% increase in the risk of later hip or knee surgery. (The 0 to 5 Larsen score includes both joint-erosion and joint-space narrowing components.) Carpenter told MedPage Today that these findings help “build the case for early treatment in rheumatoid arthritis” and support the argument that a “therapeutic window of opportunity” exists with RA.
A systematic literature review in BMJ found that most British orthopaedists use hip prostheses that have a solid evidence base. However, almost one in four hip-prosthesis brands available to UK surgeons have no evidence to support their use, and 8% of all hip prostheses implanted in 2011 had no safety or efficacy evidence available. The authors say the difficulty of running randomized controlled trials with orthopaedic implants “may…have contributed to the paucity of good quality evidence in this sphere.” They conclude that the “phased introduction of new orthopaedic implants would seem prudent.” For additional perspectives on phased introduction of orthopaedic devices, see Graduated Introduction of Orthopaedic Implants: Encouraging Innovation and Minimizing Harm in JBJS, Nov. 7, 2012.