PerspectiveFrom OT Europe

Risk of major clinical comorbidities may increase up to 2 years after hip arthroscopy

Perioperative patient screening may help reduce these comorbidities after surgery.

Patients who undergo elective arthroscopic hip surgery may experience a substantial increase in major clinical comorbidities up to 2 years postoperatively, according to results of a study published in British Journal of Sports Medicine.

“There are potentially lifestyle factors associated with these surgeries that we may not be doing our best job at screening for with patients that undergo these types of surgeries; factors that can potentially affect our outcomes,” Daniel I. Rhon, DSc, co-author of the study and assistant professor at Duke University, told Orthopedics Today. “I think this just brings more awareness to the fact there are other determinants of good or bad outcomes after surgery other than just maybe the procedure alone.”

Rise in comorbid conditions

Daniel I. Rhon, DSc
Daniel I. Rhon

Using the U.S. Military Health System Data Repository, Rhon and his colleagues collected and aggregated person-level data over 36 months for 1,870 patients undergoing arthroscopic hip surgery for femoroacetabular impingement between 2004 and 2013. Researchers examined mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders 12 months prior and 24 months after surgery, and calculated changes in frequencies and differences in proportions or comorbidities between pre-surgery and post-surgery.

After surgery, results showed statistically significant increases proportionally for all comorbidities. Researchers noted an increase in mental health disorder cases by 84%, in substance abuse disorders by 57%, in cardiovascular disorders by 71%, in metabolic syndrome cases by 85.9%, in systemic arthropathy by 132% and in sleep disorders by 111% post-surgery compared with pre-surgery. There was also a 166% increase in chronic pain diagnoses post-surgery.

“The hypothesis was that some of these comorbidities would be higher, but every single comorbidity that we looked at —and we chose comorbid conditions that are associated with orthopedic outcomes —rose after surgery, so that was surprising,” Rhon said.

Preoperative screening of patients

Although there was an association between surgery and an increase in these comorbidities, Rhon emphasized in the interview that this study could not confirm whether comorbidities were caused by the surgery.

“Based on the limitations of the data, we cannot say the surgery is what caused the comorbidities,” he said. “We just know there is a much higher rate of comorbidities afterwards.”

Due to these findings, Rhon said it is important for surgeons to screen patients preoperatively for these comorbidities that may be impacted by surgery, such as having patients complete sleep screening questionnaires and reviewing patients’ overall nutrition and physical activity levels.

“I think just broadening our outlook on how to manage these patients can likely lead to better improvements and better surgical outcomes down the road,” Rhon said. – by Casey Tingle

Disclosure: Rhon reports he has no relevant financial disclosures.

Patients who undergo elective arthroscopic hip surgery may experience a substantial increase in major clinical comorbidities up to 2 years postoperatively, according to results of a study published in British Journal of Sports Medicine.

“There are potentially lifestyle factors associated with these surgeries that we may not be doing our best job at screening for with patients that undergo these types of surgeries; factors that can potentially affect our outcomes,” Daniel I. Rhon, DSc, co-author of the study and assistant professor at Duke University, told Orthopedics Today. “I think this just brings more awareness to the fact there are other determinants of good or bad outcomes after surgery other than just maybe the procedure alone.”

Rise in comorbid conditions

Daniel I. Rhon, DSc
Daniel I. Rhon

Using the U.S. Military Health System Data Repository, Rhon and his colleagues collected and aggregated person-level data over 36 months for 1,870 patients undergoing arthroscopic hip surgery for femoroacetabular impingement between 2004 and 2013. Researchers examined mental health disorders, chronic pain, substance abuse disorders, cardiovascular disorders, metabolic syndrome, systemic arthropathy and sleep disorders 12 months prior and 24 months after surgery, and calculated changes in frequencies and differences in proportions or comorbidities between pre-surgery and post-surgery.

After surgery, results showed statistically significant increases proportionally for all comorbidities. Researchers noted an increase in mental health disorder cases by 84%, in substance abuse disorders by 57%, in cardiovascular disorders by 71%, in metabolic syndrome cases by 85.9%, in systemic arthropathy by 132% and in sleep disorders by 111% post-surgery compared with pre-surgery. There was also a 166% increase in chronic pain diagnoses post-surgery.

“The hypothesis was that some of these comorbidities would be higher, but every single comorbidity that we looked at —and we chose comorbid conditions that are associated with orthopedic outcomes —rose after surgery, so that was surprising,” Rhon said.

Preoperative screening of patients

Although there was an association between surgery and an increase in these comorbidities, Rhon emphasized in the interview that this study could not confirm whether comorbidities were caused by the surgery.

“Based on the limitations of the data, we cannot say the surgery is what caused the comorbidities,” he said. “We just know there is a much higher rate of comorbidities afterwards.”

Due to these findings, Rhon said it is important for surgeons to screen patients preoperatively for these comorbidities that may be impacted by surgery, such as having patients complete sleep screening questionnaires and reviewing patients’ overall nutrition and physical activity levels.

“I think just broadening our outlook on how to manage these patients can likely lead to better improvements and better surgical outcomes down the road,” Rhon said. – by Casey Tingle

Disclosure: Rhon reports he has no relevant financial disclosures.

    Perspective
    Bryan T. Kelly

    Bryan T. Kelly

    The general conclusions of this study are accurate and important: Comprehensive evaluation for existing or potentially hidden comorbidities is critical for all surgery. No surgical procedure is benign in nature, and the need for a period of recuperation, protected weight-bearing and limitations in physical activity is not unique to elective hip procedures.

    What is unique about non-arthritic hip pathology is the assessment and treatment algorithms require an exceptionally detailed understanding of the mechanical diagnosis that led to the pathological condition. This study does not address the complex decision-making unique to this population. Considering all hip arthroscopies as the same procedure is misleading. Just as important to the assessment of potential comorbidities is the clear delineation of the subtle mechanical nuances in patient presentation.

    The majority of the patients in this study (67.5%) were active duty military personnel, and thus these results are not necessarily generalizable beyond that population. Further investigation is necessary to indicate hip arthroscopy as a causative factor in the development of new comorbidities and, potentially, evaluating a control group without surgery over the same timeframe would be helpful.

    It is my experience that negative outcomes with hip arthroscopy are not a result of the procedure, but of a poor indication for surgery and/or technical errors in execution of the procedure. Hip arthroscopy continues to be an excellent tool to treat active individuals with life-altering hip pain when done in the appropriately selected patient and with skillful execution of the surgical procedure.

    • Bryan T. Kelly, MD
    • Center for Hip Preservation; Hospital for Special Surgery; New York

    Disclosures: Kelly reports he is a consultant for Arthrex.