Dr. Chris Tucker:
Welcome to the Arthroscopy Associations Arthroscopy Journal podcast. The views expressed in this podcast do not necessarily represent the views of the Arthroscopy Association or the Arthroscopy Journal.
Dr. Chris Tucker:
I'm Dr. Chris Tucker from the Walter Reed National Military Medical Center and founder of the podcast. I'd like to introduce Dr. Shane Nho from Midwest Orthopedics in Chicago, Illinois.
Dr. Chris Tucker:
Dr. Nho is an avid hip arthroscopy, researcher and speaker. He serves as an associate professor and co-director of the Sports Medicine Fellowship in the Department of Orthopedic Surgery at Rush University.
Dr. Chris Tucker:
Dr. Nho was the senior author on a paper titled Preoperative Predictors of Achieving Clinically Significant Athletic Functional Status After Hip Arthroscopy for FAI at Minimum 2-Year Follow-Up, which was published in the November, 2019 issue of the Arthroscopy Journal. His coauthors include Austin Stone, Edward Beck, Philip Malloy, Jorge Chahla, Benedict Nwachukwu, and William Neal.
Dr. Chris Tucker:
Welcome Shane. Thanks for joining me.
Dr. Shane Nho:
Thanks for having me, Chris.
Dr. Chris Tucker:
Shane, congratulations to you and your coauthors for the work on this study, which, I think, makes a noteworthy contribution to the growing body of knowledge with respect to improving outcomes in hip arthroscopy for FAI, specifically, in athletes. Can you start this podcast off with some background on the development and execution of your study?
Dr. Shane Nho:
Sure. As you had mentioned, a treatment of athletes with femoroacetabular impingement is certainly growing as it has been in the past decade. One of the interesting things about patients with femoroacetabular impingement is that, generally speaking, these are very young athletic patients. Historically, a lot of the outcome measures that have been used to measure how the patient's performance after surgery were really not great in terms of capturing patients ability to return to sport in terms of the right patient report outcome score, as well as the right metrics, be able to say that these patients perform well.
Dr. Shane Nho:
So what we wanted to do is... What we set out to do was to identify predictors of outcomes that would indicate patients that were doing well after hip arthroscopy with the two year follow-up. That was the goal of our study really to identify which patients that we can see in the office and say, "Hey look, this is a patient that we think would do well from surgery. These are our expectation. This is the data that we've published so far based on our experience." So I think that that was sort of the genesis behind it.
Dr. Chris Tucker:
As a bit of framework for our discussion, can you first discuss your outcome measures, specifically, the primary outcome measure which you defined as clinically significant athletic or sports function? You define that as either reaching the minimal clinically important difference, or MCID, or the patient acceptable symptomatic state, or PASS, for the hip outcome scores sports-specific at two years. Can you just describe for our listeners what the hip outcome score measures and maybe review for everybody what the MCID and PASS mean with respect to patient outcomes?
Dr. Shane Nho:
Sure. So we chose the hip outcome scores, sports specific subscale because this is the outcome score which we think best reflects what we're trying to accomplish in that is to identify patients who are returning back to athletic activities. We like this because it incorporates questions such as cutting, pivoting, jumping and running. This differs from even these hip outcome score activities of daily living subscale as well as a modified Harris hip score because these scores mostly focus in on patient's daily life activities. What was kind of the focus of this paper was to evaluate this particular score.
Dr. Shane Nho:
Now in terms of the specific thresholds that we're looking at, the first one is MCID. MCID stands for that minimally clinically important difference. And that is different than what was historically used as this statistically significant difference. I think the reason why we gravitated towards the minimally clinically important differences that in some cases while we might identify statistical significance is might not necessarily mean that a patient feels that there is a significant difference if they can determine.
Dr. Shane Nho:
So MCID has been probably one of the more common thresholds that we've used or I should say the change in scores that we've used in order to define how many points that are needed from pre-op to most recent follow-up for a patient to be able to detect a significant difference.
Dr. Shane Nho:
In this particular study are the value was a 14. So the patients had to improve by 14 points from pre-op to most recent followup for there to be considered consistent with MCID. Again, MCID is changed from pre-op to post-op. The PASS on the other hand is really, we ask the patients at two years, how are you doing, essentially, and you feel like taking account all the activities that you've done in your daily life and your functional improvement? Do you feel that your current state is satisfactory? So this is more of a score threshold.
Dr. Shane Nho:
The score that we use with 72 at two years. So if they reach a score of 72 or greater, they would be considered to have reached PASS. If they had a score of less than 72, they were considered to not have reached PASS. Those were the main metrics that we use to determine whether the patients had reached clinically significant athletic activity based on their MCID and/or pass for the hip outcome score sports-specific subscale.
Dr. Chris Tucker:
Let's get into a little bit more of the fun stuff. For our listeners taking to glean some tips from your experience in hip arthroscopy, can you share with us a few of your key pearls for success with respect to hip arthroscopy for FAI and athletes in general? Whether it be your preoperative assessment, any surgical techniques, or postoperative care that you can share with us?
Dr. Shane Nho:
Sure. I mean, I think, treating athletes is probably one of the most enjoyable and probably one of the most gratifying things that we do as orthopedic surgeons, sports medicine doctors, and arthroscopist. Caring for athletes, I think, is really a privilege. But knowing when to intervene, I think, is still a little bit of an art form. It certainly takes a careful listening to the patients in terms of what their difficulties and what their problems are. Correlating that with their history, their physical exam, and obviously their imaging plays to make it a good plan.
Dr. Shane Nho:
Not all of these cases require surgery. In many cases, they may require a lengthy period of non-operative management and in some cases they may require surgery very, very soon after the onset of symptoms. It really just depends on a case by case basis.
Dr. Shane Nho:
When dealing with in-season athletes, in general, as long as they're performing at a high level, generally speaking, I prefer to let them continue to do with what they are doing. And the reason being is that if they're able to do the athletic activities that they are trying to do, and they can do that successfully, they may need some ancillary work with the trainers, with physical therapists, with massage therapists. Maybe they need some anti-inflammatories, maybe they need some care before and after with ice and heat and other modalities. But ultimately if they're able to do what they need to do, intervening on them may not necessarily be the right decision if they're still doing it.
Dr. Shane Nho:
If the patients are demonstrating either significant amounts of pain, weakness, dysfunction, inability to perform and do what they need to do, and they really start to kind of hit a decline. That's what we're trying to figure out. That decline might occur during the season, it might occur in the off-season, but I think what's hardest to figure out at what point are they starting to start to deteriorate in terms of their overall functional status.
Dr. Shane Nho:
There's a lot of different competing interests that you have to deal with both of the patient, maybe the coaches, maybe the agent, maybe the parents, maybe the doctor, or maybe the training staff. So there's a lot of different stakeholders in this, but obviously they're priority in our allegiances with the patients first and foremost.
Dr. Shane Nho:
But I think in general, if the patients demonstrate pain, dysfunction, and then they're starting to really hit that decline, ideally what we'd like to do is treat them relatively soon when we know they've kind of start to demonstrate that.
Dr. Shane Nho:
It can be different for everybody. Sometimes it could be a pain issue. Sometimes it could be a performance issue, it could be a weakness or a functional issue. But I think that that's kind of, at least in my mind, the key because a lot of athletes will have pain. Sometimes it might just be soft tissue problems, tendonitis, either bursitis or some other issues that just need to be nurse along. Although, they may be significant complaints of pain. I guess kind of knowing when to intervene and I think to be... I still find it to be a challenging decision because it's that threshold is probably different for everybody.
Dr. Shane Nho:
From a surgical technique standpoint, in general, I think that there are three main components that we try to address during these procedures.
Dr. Shane Nho:
First is a correction of the FAI deformity. Either cam, conserved, both. That needs to be done completely and comprehensively based on and direct inspection as well as imaging at the time of surgery and dynamic examination.
Dr. Shane Nho:
The second aspect is chondrolabral refixation. In some cases, cartilage procedures like microfractures and so forth might need to be done.
Dr. Shane Nho:
And the last is capsular management, which might include either capsule repair, capsula plication.
Dr. Shane Nho:
As far as postoperative care, this I find to be really important and having a good team both in terms of in the office, therapists, and trainers, I think is critical to allow the patients to perform as best as possible, but also in a timely fashion. So I think that having an experience team that has good communication with one another. Again, having the athlete and the patient at the heart of it is, is critical for success.
Dr. Chris Tucker:
Thank you. That was a nice summary of your role as a team physician as well as your approach to your practice management, specifically, for these athletes.
Dr. Chris Tucker:
Discussing specifically this paper, the purpose of your study was to identify predictors of achieving clinically significant sport function in these athletic patients undergoing hip arthroscopy. Can you share with us your results?
Dr. Shane Nho:
So we had, in this study again, we went through our hip institutional registry between 2012 and 2016. We identified patients who were athletes. Athletes could be defined as anyone describing themselves as either recreational, high school, college, professional athletes with minimum two year follow-up. Again, in our main patient report outcome was a hip outcome scores for specific subscale. In total, we had 780 patients in methods, study criteria with 80% follow-up. We had a mean age of about 25 years.
Dr. Shane Nho:
What we found was that of those patients, 500 or 86.5 did achieve a high functional status in that 77.9% reached MCID and 68.7% reached PASS using the hip outcome score-sports specific subscale. The analysis demonstrates that we found a couple of interesting predictors for achieving MCID. What we identified was actually a increased alpha angle, preoperative pain duration, BMI, the presence of focal chondral defects and these were all considered to be negative predictors of using MCID.
Dr. Shane Nho:
When we looked at PASS, what we found was that the presence of a preoperative limp, anxiety or depression, or increased BMI, as well as preoperative pain duration were also negative predictors not for reaching PASS but for the hips outcome score-sports specifics subscale.
Dr. Chris Tucker:
One of the things I really wanted to get into with you, Shane, was you nicely described the predictors of success. There's both modifiable and non-modifiable factors. There's non-modifiable things such as the alpha angle, the presence or absence of chondral defects, pain duration, and then modifiable factors like BMI that you've now nicely identified, which are potentially good or bad in the patients interest of doing well with a hip scope. So how are you incorporating these findings into your clinical practice with respect to either patient selection or how you're managing them preoperatively with respect to timing of surgery or even offering them surgery?
Dr. Shane Nho:
Yeah. So I think that those are really good points. There's certain things that we can't change depending on when the patient lands in our office. But there are certainly somethings that we can use as ways of making decisions on some of these patients.
Dr. Shane Nho:
When you look at the predictors of MCID, a couple of them that I think are interesting and both of them really have to deal with essentially how long these patients have been dealing with this problem. So that is a preoperative pain duration as well as the presence of femoral chondral defects.
Dr. Shane Nho:
I think what we find is that when we treat these patients sooner, they don't have a long period in which they'd been dealing with this and that we're able to get to them before they developed kinds of defects. I think that's kind of changed the way that I've managed some of these patients in that... Take for example, a patient that let's say may not have stopped playing their sport, but maybe they're starting to really start to decrease their performance, spending more time in the training room. Every game, they're sitting in the ice bath or trainers are spending lots of time with them. And they're basically kind of nursing or hobbling through the season. They can still perform to some extent, but they may have to manage their minutes. They may have to do some interventions while they are in season. But I think those are the patients that we allow them to play as long as they can. But if they've reached the end of the season, they're still playing to some extent. We will recommend that they have surgery as soon as the season's done.
Dr. Shane Nho:
I think that the other scenario is, I tell them, "Look, if your pain prohibits you from playing and you really can't play or it's not fun or your performance is really suffering, then maybe it's not even worth it to get to the end of the season. And maybe the time is now."
Dr. Shane Nho:
When you look at the past, I mean, even the preop presence of the limp also suggests that they've gotten to the point where they're having obvious deep disturbances. That, obviously, is not a good sign either. I think that speaks to earlier intervention. And the other PASS factor was the preoperative pain duration. Also, again, similar thought processes. Again, just trying to get these patients sooner rather than later.
Dr. Chris Tucker:
Sure. So as a corollary to that, how are you counseling the patients who have negative predictors of success? Whether they're modifiable or not, but say they're non-modifiable. Say they've got a significantly elevated alpha angle, maybe over 70 and they've had pain for two years now and they've got a limp. They got three strikes against them. You can't change any of those factors. How are you personally counseling that patient with respect to sitting in front of them and potentially offering them a hip scope?
Dr. Shane Nho:
I mean, it definitely plays a role. I mean, some of these patients if they have a large alpha angle with a... If you had already identified a chondral defect, that looks like [inaudible 00:18:04] MRI, that's probably more likely than not that you may have to perform a microfracture. Again, speak to the extent of the disease. The way I counsel them is that in the near term, obviously their rehab is going to be more attractive because they'll be on crutches for probably about six to eight weeks for the microfracture. And while we may improve the kinematics and the biomechanics their joint, they certainly have some irreversible damage or changes that have already occurred. As you mentioned that the preoperative plan they may have developed a lot of soft tissue compensatory mechanisms as well.
Dr. Shane Nho:
All those things, I think, will speak to a longer rehab process. They may not necessarily reach MCID or PASS as predictably if they didn't have those street strikes against them. This is where I think that sometimes if you had the ability to record their baseline scores... Once in a while I'll have a patient who might kind of have this early focal chondral defect. Maybe they've got a high alpha angle but they're still somewhat functional. They have some pain but their PASS score may be relatively high.
Dr. Shane Nho:
So for those patients, sometimes it's more challenging because I'm like, "Look, your PASS score, your baseline score right now kind of meets that threshold in which you're pretty satisfied with your level of function and your pain may not be that bad in this case. Sometimes surgery may not give you the result that you're looking for." I usually go back to.... I think this is reflected in the past question. Taking into account all the activities or daily life level of pain and functional impairment, you consider your state satisfactory. So those are the main things that I ask patients is, "What's your level of pain? How does this affect your daily life? And how are your function or your recreational activities?"
Dr. Shane Nho:
I think it's always difficult when they have a low level of pain and they still can do some activities but maybe they can't do as much as they're doing five years ago. That's always a challenging one because I find that those are the ones that you really have to manage their expectations and be like, "Look, if your pain level is like a three or four, you're not going to get down to a zero if you already have some focal chondral defects it's been going out for a while." Those are the ones where I think that preoperative counseling and just kind of managing their expectations is really important.
Dr. Shane Nho:
I just tried to lay it to them and say, "This is what we see. We may or may not find that you reach MCID. You may already be at a PASS level right now. Your improvement may... There's a decent chance that you're not going to find that there's going to be significant improvement." But at the same time these are all kind of percentages and likelihood of achieving these. And there's some people that do and there's some people that don't. So I just kind of lay it out there for the patients. Just kind of be as transparent as possible with the data and just try to help them make the right decision for them.
Dr. Chris Tucker:
I think all excellent advice. All right. One other thing I wanted to pick your brain on, if we could. Your eligibility criteria for this study was consistent with what most people practice, which is failing conservative measures including oral anti-inflammatories, physical therapy, corticosteroid injections. I noticed only 58% of the enrollees had had a history of hip injection prior to having surgery. Can you just speak to the pre-op treatment for your athletes in particular and how you decide when to recommend a pre-op injection or not and any other particular factors related to that?
Dr. Shane Nho:
Sure. So I think the injections I use with my patients are usually for a couple of reasons. One is for diagnostic purposes. So for patients who have multiple locations of pain, for patients who have atypical patient of pain, or if they have sort of combine hip and back and another comorbid conditions. I think an injection can be helpful just to kind of isolate what is coming from the hip. I like it because it really allows the patients to kind of hone in and say, "All right. Following this injection, this is what we can attribute to the hip joint itself and these other sources might be indirect or they could be compensatory mechanisms that might be related to hip but by not." So I think it allows patients to have to kind of buy-in in terms of where their hip is contributing to their overall constellation of symptoms.
Dr. Shane Nho:
The second group of patients that I like to use injections on them for the patients who have a mild arthritis, or a pre-arthritic picture and which I'm really using it for that. Not for diagnostic purposes but really for therapeutic purposes. In those cases really my thought is that you might be borderline maybe you've got some chondral disease, maybe we're a little bit late to the game on this one. Let's see how you do with the injection. Let's see if it helps. How long does it last? Once in a while you'll get someone that gets six plus month for pain relief and they just could treat themselves with the occasional injection.
Dr. Shane Nho:
So for my athletes, for the young patients that, honestly, I don't love to do cortisone injection. For me, usually young athletic patients, their symptoms are usually very straightforward for the most part. I mean, once in a while I get something a little bit different or weird. But I think most of the athletes are pretty right down the middle in terms of where their symptoms are located, their presentation. And I think in both cases, I don't necessarily rely on injection because I'm not using it for diagnostic purposes. I find that they don't really don't get much pain relief from a therapeutic perspective. So I prefer not to do it unless they're really kind of in a bind and have to say they've got some commitment coming up, so if you can get some relief. But for the most part I try to avoid it if I can.
Dr. Chris Tucker:
That was kind of what I was expecting to hear, which is with respect to having only about half the patients having had an injection.
Dr. Chris Tucker:
Okay. I think we can get close to wrapping this up. I just want to give you the opportunity to share with the listeners your one take home point with respect to achieving successful improvement in athletic function following hip arthroscopy for FAI in athletes.
Dr. Shane Nho:
I think for patients who are athletic, who present us with impingement labral repairs, the way that my treatment has evolved over the years, and in part based on the studies like this is, again, really trying to allow these patients to maintain their high level of activity and function. Trying to identify at what point they're having problems and addressing it relatively efficiently so that they're not dealing with this for a long period of time. I think that that speaks to the some of the findings that we've had in terms of preoperative pain duration, presence of a preoperative limp, the presence of focal chondral defects. These are all, to me, prognostic factors that go into the algorithm as far as when we should be treating them, right?
Dr. Shane Nho:
I think in general for the athletic patients, especially if they're either in college or and a professional or something like professional level and even high school for that matter, I think that their lifespan as a competitive athlete could be relatively short. I think having them deal with a nagging injury for multiple seasons tends to be, I think, disappointing for them.
Dr. Shane Nho:
So I think I've changed the way I dealt with it. Again, it's tailored to the specific patients in that, again, knowing when they're really starting to decline in terms of their overall functional status.
Dr. Chris Tucker:
Thank you very much for sharing your thoughts with us today, Shane. I learned a lot from your paper and I learned a lot by talking with you today.
Dr. Shane Nho:
Thanks, Chris. I appreciate you inviting me to participate in the podcast.
Dr. Chris Tucker:
Our pleasure. Dr. Nho's article titled Preoperative Predictors of Achieving Clinically Significant Athletic Functional Status After Hip Arthroscopy for FAI at Minimum 2-Year Follow-Up can be found in the November, 2019 issue of the Arthroscopy Journal, which is available online at www.arthroscopyjournal.org.
Dr. Chris Tucker:
Shane, thanks again for joining us.
Dr. Shane Nho:
Thank you, Chris.
Dr. Chris Tucker:
This concludes this edition of the Arthroscopy Journal podcast. Thank you for listening. Please join us again next time.