BACKGROUND: The indications for hip arthroscopy in patients aged =40 years remain controversial, as observational studies have suggested that advanced age portends poor functional outcomes, poor durability of improvement, and high rates of conversion to total hip arthroplasty.
PURPOSE: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged =40 years with limited radiographic osteoarthritis.
STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.
METHODS: This single-surgeon, parallel randomized controlled trial included patients aged =40 years with limited osteoarthritis (Tönnis grades 0-2) who were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). Patients who received PTA and achieved unsatisfactory improvement were permitted to cross over to SPT after completing =14 weeks of physical therapy (CO). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery, and secondary outcomes included other patient-reported outcome measures and the visual analog scale for pain. The primary analysis was performed on an intention-to-treat basis using linear mixed-effects models. Sensitivity analyses included modified as-treated and treatment-failure analyses.
RESULTS: A total of 97 patients were included, with 52 (53.6%) patients in the SPT group and 45 (46.4%) patients in the PTA group. Of the patients who underwent PTA, 32 (71.1%) patients crossed over to arthroscopy at a mean of 5.10 months (SD, 3.3 months) after physical therapy initiation. In both intention-to-treat and modified as-treated analyses, the SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. In the treatment-failure analysis, the SPT and CO groups showed greater improvement across all metrics compared with PTA; however, post hoc analyses revealed no significant differences in improvement between the SPT and CO groups. No significant differences were observed between groups in rates of total hip arthroplasty conversion.
CONCLUSION: In patients =40 years of age with limited osteoarthritis, hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at a 24-month follow-up. However, additional preoperative physical therapy did not compromise surgical outcomes and allowed some patients to avoid surgery. When surgery is indicated, age =40 years should not be considered an independent contraindication to arthroscopic acetabular labral repair.
REGISTRATION: NCT03909178 (ClinicalTrials.gov identifier).
| Discipline Area | Score |
|---|---|
| Physician |  |
Physician rater
This paper concludes that surgery is more effective than physical therapy, but there is a risk of bias because of difficulty in proper standardization in the intervention.
Physician rater
It is surprising to have 32 participants out of 45 that crossed over to surgery.
Physician rater
This single-surgeon, parallel RCT compared hip arthroscopy versus nonoperative management for symptomatic labral tears in patients aged >=40 years with limited radiographic osteoarthritis. Patients were randomized to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA). The primary outcomes were the International Hip Outcome Tool-33 score and modified Harris Hip Score at 24 months after surgery. A total of 97 patients were included, with 52 and 45 patients in the SPT and PTA group, respectively. The SPT group displayed superior mean patient-reported outcome measure and pain scores across the study period for nearly all metrics relative to the PTA group. Hip arthroscopy with postoperative physical therapy led to better outcomes than PTA at 24-month follow-up.
, McMaster University