Take all factors into account; don’t rush into surgery

Peter Pollack

“In my opinion, determining when hip arthroscopy is indicated depends on several factors,” said J. W. Thomas Byrd, MD, who discussed the topic during the American Orthopaedic Society for Sports Medicine Specialty Day program. “The first is to verify that the patient’s condition is truly a hip problem.

“That seems obvious,” continued Dr. Byrd, “but one study we conducted [Clinics in Sports Medicine, Oct. 1, 2001] found that 60 percent of intra-articular disorders went unrecognized during the first 7 months of initial treatment. Extra-articular disorders may mimic and sometimes coexist with intra-articular problems. This is especially common for athletes who participate in sports that require rotational velocity, such as golf and baseball. We also know that there’s a high correlation between athletic pubalgia and hip joint problems.”

According to Dr. Byrd, patient history and a physical examination are the most powerful clinical assessment tools. Tools such as magnetic resonance imaging (MRI) and diagnostic intra-articular injections can be helpful, but may produce findings that are incomplete and not relevant to the case.

“Keep in mind that athletes with long careers may have all kinds of findings on MRIs that may have no relevance at all,” he said. “Don’t be lured by false positives, and don’t be dissuaded by false negatives.”

Dr. Byrd pointed out that one helpful clinical approach is to test the degree to which the hip is the cause of a patient’s pain by performing an intra-articular injection with anesthetic.

“It’s important for a patient to reliably invoke pain before receiving the anesthetic, so he or she can compare the response post-injection. Athletes can generate a lot more force on their hips during sports than you can generate during a passive examination,” he told the audience, “so it may be necessary to send them to a therapy or training room reproduce the activities and determine the response.”

The right patient, surgeon, and timing
Other factors in determining when hip arthroscopy is appropriate, according to Dr. Byrd, are picking the right patient and knowing your own limits as a surgeon.

“Make sure the athlete has reasonable expectations of the outcome,” he explained. “If he or she has unreasonable expectations, the operation will be deemed a failure no matter how good a job you do.

“And early in your career, start with simpler cases. It’s okay to refer complex cases. I recommend starting simple and building up to more complex procedures,” he said.

Dr. Byrd also recommended not rushing the patient into a surgical procedure, because very few problems necessitate prompt or immediate surgical intervention.

For example, published studies on femoroacetabular impingement (FAI) in athletes have found that more than 90 percent of patients had grade 3 or grade 4 articular damage at the time of surgery.

“So we’re intervening late in the disease process,” he explained. “Regardless of how suddenly the symptoms occur, remember that they are simply the culmination of the cumulative effect of a life-long disorder. Lack of immediate surgical intervention is unlikely to be harmful. If the patient’s symptoms are stable, it’s probably okay to let him or her continue playing. Will it cause more damage? Possibly, but it’s unlikely the condition will get worse without the athlete’s knowing it.”

A multitude of factors
Finally, Dr. Byrd argued that the assessment should be as complete as possible, taking into account all etiologic factors.

“There are really two modes of failure,” he said. “The first is physiologic load, such as FAI, in which an altered joint morphology breaks down under forces that would normally be tolerated by a healthy hip. In such a case, correction of the impingement may be successful and provide a more favorable long-term outlook.

“The second mode is failure due to super-physiologic loads, in which athletes are simply pushing their bodies beyond their physiologic limits. We see this often in dancers and gymnasts. The primary treatment in these cases is nonsurgical. Try to put them on a good conditioning program that will increase their physiologic limits.

“But most hip disorders are multifactorial,” he explained. “You might never identify all of the factors. Take a poorly conditioned athlete with low reserves and less ability to compensate for super-physiologic loads, add in a little dysplasia, and things can get very complicated.

“In the end, I believe that problems with poor results associated with hip arthroscopy are at least as much a problem and a consequence of poor choices, as they are of poor technique,” said Dr. Byrd.

Dr. Byrd reports the following disclosures: Smith & Nephew, A2 Surgical, Springer.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Before you operate, ask yourself
Dr. Byrd identified the following six indications for arthroscopic hip surgery:

1. Is it a hip problem?
2. Does the patient have realistic expectations?
3. Do you, as the surgeon, have the appropriate experience?
4. Is immediate surgery necessary?
5. Is it harmful to play with evidence of joint pathology?
6. Have you assessed all etiological factors as completely as possible?