Orthopedics

Feature Article 

Arthroscopic Treatment of Labral Tears in Patients 65 Years and Older

David E. Hartigan, MD; Natalia Wojnowski, BS; Aaron J. Krych, MD; Bruce A. Levy, MD; Benjamin G. Domb, MD

Abstract

The purpose of this multicenter study was to investigate the clinical outcomes after hip arthroscopy in a series of patients 65 years and older with labral tears with a minimum 2-year follow-up. Outcome data were prospectively collected and retrospectively reviewed for patients 65 years and older who underwent hip arthroscopy. Outcomes at minimum 2-year follow-up were analyzed using prospectively collected Hip Outcome Score (HOS) and modified Harris Hip Score (mHHS). A paired Student's t test was performed to determine significant differences between pre- and postoperative patient-reported outcome scores. Twenty-six patients were included, with a mean age of 67.7 years (range, 65–75 years) and mean follow-up of 50.5 months. The short-term survivorship rate was 65%, with 9 patients requiring total hip arthroplasty (THA) by latest follow-up. At minimum 2-year follow-up, mean mHHS, HOS–Activities of Daily Living, and HOS–Sports-Specific Subscale for surviving hips were 78.97 (range, 25–100), 78.56 (range, 21.7–100), and 65.93 (range, 2.78–100), respectively. The mean improvements for patients with pre- and postoperative mHHS and HOS–Sports-Specific Subscale were 28 and 36.6 (P=.0005 and P=.003, respectively). The average patient satisfaction was 7.7 on a scale of 10. There were no complications noted in this cohort. This study demonstrated that patients older than 65 years with labral pathology who have failed nonoperative measures obtain modest clinical improvement from hip arthroscopy. This clinical improvement yielded a high patient satisfaction, but due to the potential for subsequent THA in a subset of this population, surgeons should use a rigorous selection criteria and counsel patients appropriately. [Orthopedics. 2020;43(6):e579–e584.]

Abstract

The purpose of this multicenter study was to investigate the clinical outcomes after hip arthroscopy in a series of patients 65 years and older with labral tears with a minimum 2-year follow-up. Outcome data were prospectively collected and retrospectively reviewed for patients 65 years and older who underwent hip arthroscopy. Outcomes at minimum 2-year follow-up were analyzed using prospectively collected Hip Outcome Score (HOS) and modified Harris Hip Score (mHHS). A paired Student's t test was performed to determine significant differences between pre- and postoperative patient-reported outcome scores. Twenty-six patients were included, with a mean age of 67.7 years (range, 65–75 years) and mean follow-up of 50.5 months. The short-term survivorship rate was 65%, with 9 patients requiring total hip arthroplasty (THA) by latest follow-up. At minimum 2-year follow-up, mean mHHS, HOS–Activities of Daily Living, and HOS–Sports-Specific Subscale for surviving hips were 78.97 (range, 25–100), 78.56 (range, 21.7–100), and 65.93 (range, 2.78–100), respectively. The mean improvements for patients with pre- and postoperative mHHS and HOS–Sports-Specific Subscale were 28 and 36.6 (P=.0005 and P=.003, respectively). The average patient satisfaction was 7.7 on a scale of 10. There were no complications noted in this cohort. This study demonstrated that patients older than 65 years with labral pathology who have failed nonoperative measures obtain modest clinical improvement from hip arthroscopy. This clinical improvement yielded a high patient satisfaction, but due to the potential for subsequent THA in a subset of this population, surgeons should use a rigorous selection criteria and counsel patients appropriately. [Orthopedics. 2020;43(6):e579–e584.]

The use of hip arthroscopy has been growing during the past decade and has been successful in the treatment of labral tears.1,2 Traditionally, arthroscopic hip surgery has been performed predominantly in younger patients, with numerous authors documenting positive patient-reported outcome (PRO) scores at 2 and 10 years.3–9 Several authors have also reported satisfactory outcomes in patients older than 50 years and even patients older than 60 years, but careful patient selection was recommended.2,10–12

Current literature suggests that older age and radiographic signs of osteoarthritis have been negative prognostic factors for PRO scores following hip arthroscopy and might be a risk for conversion to total hip arthroplasty (THA).12–15 However, there still exists an increasing population of active older patients with intra-articular hip pain and/or limitation who have failed conservative measures and are not candidates for THA.

Currently, there are no published data regarding the outcomes of arthroscopic treatment of the hip in patients 65 years and older. Therefore, the purpose of this multicenter study was to investigate the clinical outcomes after hip arthroscopy in a series of patients 65 years and older with labral tears with a minimum 2-year follow-up. The authors' hypothesis was that patients 65 years and older would have favorable functional outcomes as measured by validated PRO scores.

Materials and Methods

Study Design

This investigation was a retrospective review of prospectively collected data on patients who underwent hip arthroscopy for treatment of a labral tear at 2 institutions between August 2007 and November 2016 after failure of nonoperative treatment. Both institutions' databases for hip arthroscopy were used to identify 26 patients who underwent surgery between the listed dates at 2 high-volume hip centers. This consisted of less than 1% of hip scopes performed at both centers. All patients gave written consent to participate in the study, and both institutional review boards approved this study.

Inclusion/Exclusion Criteria

The study population included patients who presented with labral tears and under-went primary arthroscopic treatment by 2 experienced orthopedic surgeons (B.A.L., B.G.D.) from August 2007 to November 2016. Patients were eligible for the study if they were 65 years or older at the time of surgery, with a minimum of 2 years of follow-up. Patients were excluded if they had greater than Tönnis grade 2 arthritis, inflammatory arthritis, Perthes disease, avascular necrosis of the hip, or abductor repairs done concurrently or had undergone previous hip surgery.

Diagnostic Workup

Diagnostic criteria for confirming a labral tear included patient history, physical examination findings such as positive anterior impingement sign, and presence of labral tear/pathology on magnetic resonance imaging (MRI). Magnetic resonance images were read by 2 board-certified orthopedic surgeons (B.A.L., B.G.D.) and recorded in the database. Both 1.5- and 3.0-Tesla scanners were used. Patient demographics such as sex, age, and months of follow-up were recorded. Conversion to THA was recorded. Indication for surgery was failure of at least 6 months of nonoperative management, which consisted of nonsteroidal anti-inflammatory drugs, physical therapy, activity modifications, and intra-articular corticosteroid injection. All patients experienced pain relief with the injection; however, it was transient. If patients continued to experience pain with activities of daily living, they were selected for hip arthroscopy.

Anteroposterior pelvis, false profile, and 45° Dunn view radiographs were obtained for preoperative evaluation of patients. These views were used to calculate the lateral center-edge angle, alpha angle, anterior center-edge angle, and Tönnis grade of osteoarthritis.

Surgical Procedure

All patients underwent hip arthroscopy in the supine position by the 2 senior authors (B.A.L., B.G.D.). Diagnostic arthroscopy included grading of articular cartilage lesions. Intraoperative data were recorded for all patients, including acetabular and femoral Outerbridge grade.16,17 Labral tears were treated with either debridement or repair. The labrum was determined to be irreparable in the majority of patients. Both surgeons made the determination to debride based on the quality of the labral tissue encountered as well as having the preconceived bias that patients older than 65 years will have limited healing capacity. Labral debridement was performed with the goal of obtaining a stable rim of labral tissue. The amount of resected labrum was not quantified. Labral repair, when indicated, was performed in a simple loop fashion, compressing labral tissue down to the acetabulum for healing. The suction seal was observed to be restored on visualization of the femoral head and labrum interface from the peripheral compartment. Acetabuloplasty was only performed on patients who had focal or global acetabular overcoverage, and femoroplasty was only performed on patients with an alpha angle greater than 55°. The ligamentum teres was evaluated in all cases. If there was degenerative tearing present and it was thought by the treating surgeon that the degenerative tissue could fall into the joint and cause irritation and/or mechanical symptoms, then a combination of a shaver and flexible cautery device was used to debride and shrink down this tissue to avoid further irritation. The capsule was either repaired or released depending on the patient's preoperative motion, cartilage status at the time of the operation, and the time period in which the surgery was performed (selective capsular repair performed beginning in 2010). Patients who demonstrated more objective stiffness on preoperative examination, had more chondral damage at the time of surgery, or who were operated on prior to 2010 had a capsular release. Patients with borderline dysplasia or ligamentous laxity had capsular closures (if performed after capsular closure began).

Rehabilitation

All patients were instructed to be touch-down weight bearing for 2 weeks. Slow progression to full weight bearing was initiated after this 2-week period. Slow progression to full strength and activity was progressed during a 3- to 4-month period as described by Spencer-Gardner et al.18

Functional and Clinical Assessment/Patient-Reported Outcome Scores

Patients were routinely asked to complete 3 questionnaires at 12 months, 24 months, and 60 months postoperatively to determine clinical outcome. These questionnaires included the visual analog scale (VAS), the modified Hip Harris Score (mHHS), and the Hip Outcome Score (HOS). The mHHS and HOS have been used commonly after hip arthroscopy and have high validity.19–22 For this study, HOS subscales of activities of daily living and sport were used in the analysis. These data were analyzed for the patients who did not require conversion to THA. Patient satisfaction with surgery was measured by asking patients, “How satisfied are you with your surgical result?” Ten was the best result possible. Minimally clinically important differences23 (MCIDs) are a measure of the ability of patients to be able to perceive a difference in their status. For the PROs that the authors examined, mHHS and HOS–Sports-Specific Subscale (HOS–SSS), the MCIDs are 8 and 6 points, respectively, as reported by Kemp et al.24 The authors' changes in these metrics were compared with these known MCIDs to discern whether patients had a perceivable change in status.

Statistical Analysis

Descriptive statistics were used to report frequencies and means for the cohort and subgroups. The authors assessed for statistically significant improvements in PROs and VAS scores at minimum 2-year follow-up. Shapiro-Wilk tests were performed to determine whether data were normally distributed. A two-tailed paired t test was performed to compare normally distributed data, and the Wilcoxon test was used for non-normally distributed data. All statistics were performed using Excel (Microsoft, Redmond, Washington). P<.05 was considered statistically significant.

Results

During the study period, 5082 hip arthroscopies were performed at both institutions. Overall, 26 patients (0.5% of hip arthroscopies) were 65 years or older at the time of surgery and met all inclusion and exclusion criteria. There were 11 males and 15 females, 13 right hips and 13 left hips. Minimum length of follow-up was 2 years, with a mean follow-up of 50.5 months (Table 1). Thirteen patients had preoperative and postoperative VAS pain scores, mHHS, and HOS–SSS. The remaining 13 patients did not have preoperative scores (Figure 1). Seventeen of the patients completed an evaluation of postoperative satisfaction with the surgery on a scale of 1 to 10. Procedures performed at the time of hip arthroscopy are noted in Table 2. All patient radiographs were analyzed preoperatively, and these data are presented in Table 3. A thorough evaluation of the chondral surfaces was conducted in all patients, and the findings are presented in Table 4. There were no complications noted in this cohort.

Patient Demographics

Table 1:

Patient Demographics

Flow diagram demonstrating the number of arthroscopies performed during the study period, and those excluded due to exclusion criteria. Twenty-six hips met the inclusion criteria. Thirteen had preoperative patient-reported outcomes (PROs): visual analog scale score, modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, and Hip Outcome Score–Sports-Specific Subscale. Thirteen patients did not have preoperative PROs. Of the 13 patients with preoperative PROs, 7 had postoperative satisfaction data. Of the 13 without PROs, 9 had postoperative satisfaction scores.

Figure 1:

Flow diagram demonstrating the number of arthroscopies performed during the study period, and those excluded due to exclusion criteria. Twenty-six hips met the inclusion criteria. Thirteen had preoperative patient-reported outcomes (PROs): visual analog scale score, modified Harris Hip Score, Hip Outcome Score–Activities of Daily Living, and Hip Outcome Score–Sports-Specific Subscale. Thirteen patients did not have preoperative PROs. Of the 13 patients with preoperative PROs, 7 had postoperative satisfaction data. Of the 13 without PROs, 9 had postoperative satisfaction scores.

Intraoperative Procedures Performed on Patients Who Underwent Hip Arthroscopy

Table 2:

Intraoperative Procedures Performed on Patients Who Underwent Hip Arthroscopy

Preoperative Radiographic Measurements

Table 3:

Preoperative Radiographic Measurements

Patient Demographics and Intraoperative Cartilage Findings Noted at Arthroscopy

Table 4:

Patient Demographics and Intraoperative Cartilage Findings Noted at Arthroscopy

The mean PRO scores for the patients who had both preoperative and postoperative scores improved as follows: mHHS, from 63.41 to 89.31 (P=.0005); HOS–SSS, from 43.66 to 80.30 (P=.003) (Figure 2). The average VAS score was 4.9 preoperatively and 1.27 postoperatively (P=.001) (Figure 3). Of the 17 patients asked about postoperative satisfaction on a scale of 1 to 10, the average response was 7.7 (range, 3–10). The mean changes for mHHS and HOS–SSS in the cohort were 28 and 36.3, respectively, both of which exceed the MCID. The average greater than 2-year outcome for all patients who did not undergo THA prior to 24 months for mHHS, HOS–Activities of Daily Living (HOS–ADL), and HOS–SSS were 78.97, 78.56, and 65.93, respectively.

Preoperative and postoperative (≥2 years) modified Harris Hip Score (mHHS) and Hip Outcome Score–Sports-Specific Subscale (HOS–SSS) for the patients who had both preoperative and postoperative patient-reported outcomes. *Statistically significant.

Figure 2:

Preoperative and postoperative (≥2 years) modified Harris Hip Score (mHHS) and Hip Outcome Score–Sports-Specific Subscale (HOS–SSS) for the patients who had both preoperative and postoperative patient-reported outcomes. *Statistically significant.

Preoperative and postoperative (≥2 years) visual analog scale (VAS) scores for pain. **Statistically significant in 13 patients who had both preoperative and postoperative patient-reported outcomes.

Figure 3:

Preoperative and postoperative (≥2 years) visual analog scale (VAS) scores for pain. **Statistically significant in 13 patients who had both preoperative and postoperative patient-reported outcomes.

There were 9 (34.6%) patients requiring THA at an average of 23.6 months after arthroscopy at latest follow-up. The short-term survivorship at 2 years after arthroscopy was 77%. All patients with a conversion to THA had intraoperative findings of cartilage damage either on the acetabulum or on the femoral head. Five patients converted to THA within 12 months (average, 5.4 months). Of these 5 patients, 3 had Outerbridge grade IV chondral damage to the weight-bearing portion of their acetabulum. The other 2 patients had Outerbridge grade II lesions on the acetabulum.

Discussion

This multicenter study assessed postoperative outcomes in patients 65 years and older with greater than 2-year outcomes. The overall rate of 2-year survivorship was 65% for this study. The group of patients who did not undergo THA demonstrated significant improvement in HOS–SSS and mHHS scores. Mean improvement in all scores exceeded the MCID. Patient satisfaction was an average of 7.7 on a scale of 10, suggesting that patients were satisfied with their result.

Redmond et al2 evaluated 30 patients 60 years and older undergoing hip arthroscopy for labral pathology. In that study, conversion to THA was required in 9 (30%) patients at a mean of 1.1 years following arthroscopy. Their findings also included improvement in mean PRO scores (mHHS from 63.0 to 80.1; HOS–ADL from 64.1 to 80.4; HOS–SSS from 48.2 to 63.4), and all scores except HOS–SSS showed significance. In the subgroup analysis, the group of patients who required THA reported lower preoperative means for mHHS and HOS–ADL compared with patients who did not require THA. Patients with a preoperative mHHS less than 50 were 2.6 times more likely to undergo conversion to THA.

Philippon et al11 evaluated 153 patients 50 years and older who underwent hip arthroscopy for femoroacetabular impingement. Their findings included a noted effect of joint space narrowing in patients requiring THA, with 43% of patients with less than 2 mm of joint space remaining requiring THA. Patients with more than 2 mm of joint space remaining had only a 10% rate of conversion to THA. Patients who did not require THA reported significant improvement in PRO scores (mHHS from 58 to 84; HOS–ADL from 66 to 87; HOS–SSS from 42 to 72). The current study only had 2 patients who went on to THA; therefore, subgroup analysis would have been underpowered to draw any conclusion.

Several studies have noted older age and degenerative changes on radiographs to be negative predictive factors after hip procedures.3,8,12–15,25–27 However, there is a subset of elderly patients with well-maintained joint space who experience pain. In addition, many chondral lesions can go undetected on MRI.27,28 It is apparent from the current study that patients 65 years and older undergoing hip arthroscopy have lower postoperative PRO scores compared with current literature reporting on younger cohorts8,26,28 but have statistically significant improvement in HOS–ADL, HOS–SSS, and mHHS from their preoperative status. Patients also seem to be satisfied with their surgical intervention on questioning 2 years postoperatively and have a low rate of conversion to THA at short-term follow-up.

This study had several strengths. To the authors' knowledge, it is the first study to evaluate a population in this age group. Two high-volume hip preservation centers were used to increase generalizability and patient numbers in a rare hip arthroscopy demographic. This study had 100% follow-up on all patients with greater than 2-year outcomes. These results may benefit counseling a population of patients 65 years and older who remain active and present with hip pain recalcitrant to nonoperative treatment. The limitations of this study included the lack of a control group for analysis and the small patient cohort. Thirteen patients did not have preoperative PROs, and 10 patients did not have postoperative satisfaction numbers, so the study may have been underpowered. However, with an uncommon problem, it gives providers data to discuss with their patients. The current metrics to examine hip arthroscopy are designed for patients who are younger than the current study's population. With a population 65 years and older, the construct validity, interpretability, responsiveness, and reliability of these PROs are brought into question.23 Using tests that examine an older population may be more appropriate for this cohort in future studies. The current study had 2-year or greater follow-up, which is short term, and thus the results may not be generalizable to longer follow-up.

Conclusion

This study demonstrated that patients 65 years and older with labral pathology who failed nonoperative measures obtained modest clinical improvement from hip arthroscopy. This clinical improvement yielded high patient satisfaction. There was an increased risk of conversion to THA in this cohort compared with younger arthroscopy patients.

References

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Patient Demographics

CharacteristicValue
Patients, Total no.26
Age at surgery, mean±SD (range), y67.72±2.40 (65.07–74.71)
Sex, male/female, No.11/15
Surgery side, right/left, No.13/13
Follow-up, mean±SD (range), mo50.52±26.32 (24–119.33)
Conversion to THA, No.9 (34.6%)
Time to conversion to THA, average (range), mo23.60 (2–88.5)

Intraoperative Procedures Performed on Patients Who Underwent Hip Arthroscopy

ProcedureNo. (%)
Femoroplasty10 (38.5)
Femoral chondroplasty3 (11.5)
Acetabuloplasty7 (26.9)
Acetabular chondroplasty6 (23.1)
Loose body removal6 (23.1)
Troch bursectomy4 (15.4)
Ligamentum teres treatment17 (65.4)
Microfracture2 (7.7)
Labral
  Debridement21 (80.8)
  Repair5 (19.2)
Capsule
  Repair3 (11.5)
  Release23 (88.5)

Preoperative Radiographic Measurements

MeasurementValue
Alpha angle, mean±SD (range)58.1°±9.96° (39.1°–74°)
Lateral center-edge angle, mean±SD (range)30.8°±6.37° (16°–47.1°)
Anterior center-edge angle, mean±SD (range)31.8°±4.52° (26°–40°)a
Tönnis grade, No.
  09
  115
  22

Patient Demographics and Intraoperative Cartilage Findings Noted at Arthroscopy

ItemNo.
Patients26
Sex, male/female11/15
Acetabular Outerbridge grade
  03 (11.5%)
  15 (19.2%)
  211 (42.3%)
  32 (7.7%)
  45 (19.2%)
Femoral Outerbridge grade
  019 (73.1%)
  11 (3.8%)
  21 (3.8%)
  34 (15.4%)
  41 (3.8%)
Authors

The authors are from Twin Cities Orthopedics (DEH), Maple Grove, Minnesota; Northwestern University Feinberg School of Medicine (NW), Chicago, Illinois; the Department of Orthopedic Surgery (AJK, BAL) and the Sports Medicine Center (AJK), Mayo Clinic, Rochester, Minnesota; and the American Hip Institute, Des Plaines, and AMITA Health St Alexius Medical Center (BGD), Hoffman Estates, Illinois.

Ms Wojnowski has no relevant financial relationships to disclose. Dr Hartigan is a paid consultant for Arthrex, Biomet Orthopedics, and Smith & Nephew; has received a grant from Arthrex; and has received non-financial support from Arthrex, Biomet Orthopedics, DePuy Synthes Sales, Desert Mountain Medical, Medtronic Vascular, Peerless Surgical, Smith & Nephew, Stryker, and Zimmer Biomet. Dr Krych is a paid consultant for Arthrex; has received a grant from Aesculap Biologics; and has received non-financial support from Arthrex, Ceterix Orthopaedics, Gemini Medical, Smith & Nephew, and Vericel Corporation. Dr Levy is a paid consultant for Arthrex and Smith & Nephew and has received non-financial support from Arthrex, Gemini Medical, and Smith & Nephew. Dr Domb is a paid consultant for Amplitude, Arthrex, DJO Global, Medacta, Pacira Pharmaceuticals, Stryker, and Orthomerica; has received grants from Arthrex, Medacta, Stryker, Pacira Pharmaceuticals, and Breg; has received non-financial support from Amplitude, Arthrex, Pacira Pharmaceuticals, and Stryker; and has patents with Arthrex, Orthomerica, and DJO Global.

Correspondence should be addressed to: Benjamin G. Domb, MD, American Hip Institute, 999 E Touhy Ave, Ste 450, Des Plaines, IL 60018 ( DrDomb@americanhipinstitute.org).

Received: May 22, 2019
Accepted: October 21, 2019
Posted Online: September 03, 2020

10.3928/01477447-20200827-09

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