Many orthopaedists wonder whether—or under what circumstances—arthroscopy confers any clinical benefit in treating hip osteoarthritis. A prospective matched-pair analysis by Chandrasekaran et al. in the June 15, 2016 Journal of Bone & Joint Surgery suggests that arthroscopy does not help prevent the eventual conversion to total hip arthroplasty (THA) in hips with Tönnis grade-2 arthritis (moderate narrowing of the joint space with moderate loss of femoral-head sphericity).
The authors compared two-year outcomes from 37 patients with Tönnis grade-2 hip osteoarthritis who had a hip arthroscopy performed with outcomes from matched cohorts of 37 Tönnis grade-0 and 37 grade-1 hips on which arthroscopy was also performed. In all cases, arthroscopy sought to address symptomatic intra-articular hip disorders refractory to nonoperative management. The cohorts were matched to minimize the confounding effects of age, sex, and BMI on the outcomes.
There were no significant differences among the groups with respect to four patient-reported outcome measures (including the modified Harris hip score), VAS pain scores, and patient satisfaction levels. However, Tönnis grade-2 hips had a significantly higher conversion rate to THA compared to the other two matched cohorts. In absolute terms, a subsequent THA was required for 3 hips in the Tönnis grade-0 group, 5 in the Tönnis grade-1 group, and 15 in the Tönnis grade-2 group.
From this finding, the authors conclude that “hip arthroscopy has a limited role as a joint preservation procedure in select patients with Tönnis grade-2 osteoarthritis…Hip arthroscopy can effectively restore the labral seal and address impingement, but patients may continue to experience symptoms associated with the osteoarthritis.”
Every clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD