Safety evaluation of a strategy to restart elective orthopaedic surgery during the de-escalation phase of the COVID-19 pandemic.

AIMS: To evaluate safety outcomes and patient satisfaction of the re-introduction of elective orthopaedic surgery on 'green' (non-COVID-19) sites during the COVID-19 pandemic. METHODS: A strategy consisting of phased relaxation of clinical comorbidity criteria was developed. Patients from the orthopaedic waiting list were selected according to these criteria and observed recommended preoperative isolation protocols. Surgery was performed at green sites (two local private hospitals) under the COVID-19 NHS contract. The first 100 consecutive patients that met the Phase 1 criteria and underwent surgery were included. In hospital and postoperative complications with specific enquiry as to development of COVID-19 symptoms or need and outcome for COVID-19 testing at 14 days and six weeks was recorded. Patient satisfaction was surveyed at 14 days postoperatively. RESULTS: There were 54 females and 46 males (mean age 44 years, mean body mass index (BMI) 25.6 kg/m2). In all, 56 patients underwent major orthopaedic procedures. There were no exclusions. One patient had a postoperative positive SARS-CoV-2 RT-PCR test but had no typical symptoms of COVID-19 infection and no clinical sequelae. 99% of patients were satisfied with the process and 98% would recommend undergoing elective orthopaedic surgery in the study period. CONCLUSION: In an environment with appropriate infrastructure, patient selection, isolation, screening, and testing, elective orthopaedic surgery is safe during the COVID-19 pandemic, and associated with high patient satisfaction. Further follow-up is required to establish that safety is maintained as the clinical restrictions are eased with the phased approach described.Cite this article: Bone Joint Open 2020;1-8:450-456.

Arthroscopic hip surgery compared with physiotherapy and activity modification for the treatment of symptomatic femoroacetabular impingement: multicentre randomised controlled trial.

OBJECTIVE: To compare arthroscopic hip surgery with physiotherapy and activity modification for improving patient reported outcome measures in patients with symptomatic femoroacetabular impingement (FAI). DESIGN: Two group parallel, assessor blinded, pragmatic randomised controlled trial. SETTING: Secondary and tertiary care centres across seven NHS England sites. PARTICIPANTS: 222 participants aged 18 to 60 years with symptomatic FAI confirmed clinically and with imaging (radiography or magnetic resonance imaging) were randomised (1:1) to receive arthroscopic hip surgery (n=112) or a programme of physiotherapy and activity modification (n=110). Exclusion criteria included previous surgery, completion of a physiotherapy programme targeting FAI within the preceding 12 months, established osteoarthritis (Kellgren-Lawrence grade ≥2), and hip dysplasia (centre-edge angle <20 degrees). INTERVENTIONS: Participants in the physiotherapy group received a goal based programme tailored to individual patient needs, with emphasis on improving core stability and movement control. A maximum of eight physiotherapy sessions were delivered over five months. Participants in the arthroscopic surgery group received surgery to excise the bone that impinged during hip movements, followed by routine postoperative care. MAIN OUTCOME MEASURES: The primary outcome measure was the hip outcome score activities of daily living subscale (HOS ADL) at eight months post-randomisation, with a minimum clinically important difference between groups of 9 points. Secondary outcome measures included additional patient reported outcome measures and clinical assessment. RESULTS: At eight months post-randomisation, data were available for 100 patients in the arthroscopic hip surgery group (89%) and 88 patients in the physiotherapy programme group (80%). Mean HOS ADL was 78.4 (95% confidence interval 74.4 to 82.3) for patients randomised to arthroscopic hip surgery and 69.2 (65.2 to 73.3) for patients randomised to the physiotherapy programme. After adjusting for baseline HOS ADL, age, sex, and study site, the mean HOS ADL was 10.0 points higher (6.4 to 13.6) in the arthroscopic hip surgery group compared with the physiotherapy programme group (P<0.001)). No serious adverse events were reported in either group. CONCLUSIONS: Patients with symptomatic FAI referred to secondary or tertiary care achieve superior outcomes with arthroscopic hip surgery than with physiotherapy and activity modification. TRIAL REGISTRATION: ClinicalTrials.gov NCT01893034.

Factors increasing risk of failure following hip arthroscopy: a case control study.

We aimed to identify factors such as pre-arthroscopy and intra-operative variables that were associated with failure of hip arthroscopy as a joint preserving operation. We performed a retrospective analysis of a database containing 344 consecutive hip arthroscopies performed at our institution. Forty-four hips were identified that underwent a subsequent arthroplasty procedure following their hip arthroscopy (cases). Sixty-six control hips (hip arthroscopy with no subsequent arthroplasty) were randomly selected from the same database. Cases and controls were matched for age, sex and follow-up (P = 0.59, 0.48, 0.10, respectively). Pre-operative radiographs/MRI scans plus intra-operative findings were analysed to identify factors associated with failure. Both a lower centre edge angle and higher acetabular index on pre-operative radiographs were associated with higher rates of failure (P < 0.001). The presence of any acetabular wear at operation was also associated with failure (P < 0.001). Highest rates of failure were seen in hips with both features of dysplasia on pre-operative radiographs and any intra-operative acetabular wear (relative risk: 5, odds ratio: 9.13, P < 0.001). Dysplastic features on pre-operative radiographs and the finding of acetabular wear at hip arthroscopy increase the risk of subsequent arthroplasty. Identification of these features pre-operatively with evolving imaging techniques would improve the results of hip arthroscopy as joint preserving surgery.

A Traffic Light Grading System of Hip Dysplasia to Predict the Success of Arthroscopic Hip Surgery.

BACKGROUND: The role of hip arthroscopic surgery in dysplasia is controversial. PURPOSE: To determine the 7-year joint preservation rate after hip arthroscopic surgery in hip dysplasia and identify anatomic and intraoperative features that predict the success of hip preservation with arthroscopic surgery, allowing the formulation of an evidence-based classification system. STUDY DESIGN: Case-control study; Level of evidence, 3. METHODS: Between 2008 and 2013, 111 hips with dysplastic features (acetabular index [AI] >10° and/or lateral center-edge angle [LCEA] <25°) that underwent arthroscopic surgery were identified. Clinical, radiological, and operative findings and the type of procedure performed were reviewed. Radiographic evaluations of the operated hip (AI, LCEA, extrusion index) were performed. Outcome measures included whether the hip was preserved (ie, did not require arthroplasty) at follow-up and the preoperative and postoperative Non-Arthritic Hip Score (NAHS) and Hip disability and Osteoarthritis Outcome Score (HOOS). The AI and LCEA were calculated, factored by a measure of articular wear (AIf and LCEAf, respectively), according to the University College Hospital, London (UCL) grading system as follows: AIf = AI × (number of UCL wear zones + 1), and LCEAf = LCEA / (number of UCL wear zones + 1). A contour plot of the resulting probability value of failure for every combination of AIf and LCEAf allowed for the determination of the zones with the lowest and highest incidences of failure to preserve the hip. RESULTS: The mean AI and LCEA were 9.8° and 18.0°, respectively. At a mean follow-up of 4.5 years (range, 0.4-8.3 years), 33 hips had failed, requiring hip arthroplasty. The 7-year joint survival rate was 68%. The mean improvements in the NAHS and HOOS were 11 ( P = .001) and 22.8 ( P < .001) points, respectively. The zone with the greatest chance of joint preservation (odds ratio, 10; P < .001) was the green zone, with an AIf of 0° to 15° and an LCEAf of 15° to 25°; in contrast, the zone with the greatest chance of failure (odds ratio, 10; P < .001) was the red zone, with an AIf of 20° to 100° and an LCEAf of 0° to 10°. CONCLUSION: Overall, the 7-year hip survival rate in hip dysplasia appears inferior compared with that reported in femoroacetabular impingement (78%). Hip arthroscopic surgery is associated with an excellent chance of hip preservation in mild dysplasia (green zone: AI = 0°-15°, LCEA = 15°-25°) and no articular wear. The authors advise that the greatest caution should be used when considering arthroscopic options in cases of severe dysplasia (red zone: AI >20° and/or LCEA <10°).

Outcomes of Hip Arthroplasty After Failed Hip Arthroscopy: A Case-Control Study.

BACKGROUND: Hip arthroscopy is increasingly being used in joint preservation surgery with clear benefits in the treatment of prearthritic conditions. A number of patients, however, will still go on to require subsequent hip arthroplasty, and at present, little evidence exists determining the impact that prior hip arthroscopy may have on the outcomes of a subsequent arthroplasty. METHODS: Using prospectively collated data, we identified 35 patients who had a hip arthroplasty (22 total hip arthroplasties and 13 hip resurfacing arthroplasties) after prior ipsilateral hip arthroscopy (cases). Cases were matched for age, gender, and prosthesis type with 70 controls (patients who received a primary arthroplasty over the same period, without prior arthroscopy). Outcome measures included range of movement, implant survival, complications, and functional outcome (Oxford Hip Score and Harris Hip Score). RESULTS: There was no demonstrable difference in improved range of motion after hip arthroplasty between the 2 groups, across any axis of movement (flexion, extension, internal/external rotation, abduction, and adduction; P = .07-.78). There was no significant difference in complication rate (P = .72). Overall 7-year implant survival was 85.9% (95% confidence interval [CI], 75-95.8). There was no difference in survival between cases (87.6%; 95% CI, 73.5-100) and controls (86.3%; 95% CI, 74.6%-98.0%; P = .2). Ten of the 11 revision arthroplasties performed were due to adverse reactions to metal debris in metal-on-metal hip resurfacing arthroplasty cases (P = .01). There was no difference in improvement of functional outcome postarthroplasty between groups (P = .48-.76). CONCLUSION: This study demonstrates that hip arthroscopy does not adversely influence outcome of a subsequent hip arthroplasty.