Metal-on-metal hip resurfacing arthroplasty (HRA) remains an alternative to total hip arthroplasty (THA) in appropriately selected, younger, active adults with degenerative hip disease.1-4 While concerns remain regarding the potential for adverse local tissue reactions from wear of the metal-on-metal bearing surface,5-8 10-year data from the Australian Orthopaedic Association National Joint Replacement Registry Annual Report9 showed a revision rate of only 6.3% when the Birmingham Hip Resurfacing (BHR) System was used (Smith & Nephew Inc, Memphis, Tennessee).In addition, in an independent review of 230 consecutive BHRs at a mean follow-up of 10.4 years, Coulter and colleagues10 showed encouraging clinical results, with a mean Oxford Hip Score of 45.0 and a mean University of California at Los Angeles (UCLA) activity score of 7.4.
Similar to the prior increase in popularity of HRA, hip arthroscopy has also become much more commonplace, and its indications continue to evolve.11 Hip arthroscopy has been used in the native hip joint to manage femoroacetabular impingement, labral tears, and iliopsoas tendinopathy, among other conditions.12 In addition, the use of hip arthroscopy has not been limited to the native hip but also has increased as a diagnostic and therapeutic procedure after hip arthroplasties. Bajwa and Villar12 found hip arthroscopy to be diagnostic in 23 of 24 patients who underwent the procedure after a hip arthroplasty, concluding that arthroscopy is a useful adjunct in the diagnosis of symptomatic arthroplasties.
Therefore, hip arthroscopy has been shown to be an effective modality to treat pathology in both the native hip and after hip arthroplasties. However, the effect of a prior hip arthroscopy on the outcome of a subsequent metal-on-metal HRA has not been determined. Piedade and colleagues13 showed a prior knee arthroscopy to increase the risk of postoperative complications and subsequent revision after total knee arthroplasty. Complications included reflex sympathetic dystrophy, undiagnosed pain, infection, stiffness, and component loosening. A prior osteochondroplasty at the femoral head-neck junction could increase the risk of femoral neck fracture after a subsequent HRA. Thus, the purpose of this study was to evaluate the clinical outcomes of a series of patients who received an HRA after a prior hip arthroscopy and to compare these results with a cohort of patients who received an HRA with no prior hip surgeries. Our hypothesis is that a prior hip arthroscopy will lead to inferior outcomes in patients undergoing HRA.
Materials and Methods
This study is a retrospective, case-control study using a 1:2 matching analysis. Dr. Su performed all HRAs, which were enrolled in an institutional review board–approved arthroplasty registry. All HRAs were performed using the BHR System.
The surgical technique for hip resurfacing arthroplasty has been described.1 All procedures were performed via a posterior approach with the patient in the lateral decubitus position. All patients received a hybrid metal-on-metal hip resurfacing, with an uncemented acetabular component and cemented femoral component. Intraoperative anesthesia for all patients was performed via a combined spinal-epidural anesthetic, and an epidural patient-controlled analgesic was used for the first day postoperatively, followed by a transition to oral analgesics. The sizes of the acetabular and femoral components were recorded for each hip resurfacing. Postoperatively, intermittent pneumatic compression devices were placed upon arrival in the recovery room, and active ankle flexion and extension exercises were initiated immediately after the patient’s neurologic function returned.14 Aspirin was used for chemical deep venous thrombosis prophylaxis in all patients postoperatively for a period of 6 weeks. Full weight-bearing, with the use of crutches for assistance with balance, was permitted immediately. Crutches were used for a period of 3 weeks prior to being discontinued.
From a database of 1357 HRAs (all BHR implants) performed between June 2006 and June 2012, 51 patients were identified who received an HRA after a prior hip arthroscopy. Eight patients were excluded because they did not possess adequate clinical documentation or were lost to follow-up. In the remaining 43 patients, there were 32 men and 11 women (21 right hips, 22 left hips), which formed the arthroscopy cohort. Two patients had a history of multiple hip arthroscopies (1 patient with 2 prior procedures, 1 patient with 3 prior procedures). The mean (SD) time from the most recent hip arthroscopy to the HRA was 2.5 (2.5) years. Table 1 presents a summary of the hip arthroscopy procedures (including only the most recent hip arthroscopy procedure in those with multiple arthroscopies).
Patient demographic variables (age, body mass index [BMI]) were recorded preoperatively, along with the Harris Hip Score (HHS),15 UCLA activity score,16 Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score,17 and preoperative hip range of motion (flexion, extension, abduction, adduction, internal rotation, and external rotation). The same clinical indices were assessed postoperatively along with the Short Form-12 (SF-12) Health Survey Score,18 at the 6-week, 3-month, 6-month, 1-year, and most recent follow-up visits.