Sujith Konan

Hip Arthroscopy: Analysis of a Single Surgeon's Learning Experience

BACKGROUND The aim of this study was to objectively quantify a surgeons learning experience for hip arthroscopy. METHODS We prospectively reviewed the first 100 hip arthroscopic procedures performed between 1999 and 2004 by a single experienced consultant orthopaedic surgeon. In the second part of the study, three groups of patients were sequentially analyzed: Group 1 included the first thirty patients treated by the surgeon; group 2, the sixty-first through ninetieth patients; and group 3, the 121st through 150th patients. The groups were compared with regard to the diagnosis, the duration of the central and peripheral compartment procedure, patient satisfaction, conversion to arthroplasty, and the nonarthritic hip score. RESULTS There was a decrease in complications from the first thirty cases to the remaining seventy operations. There was an overall decrease in operative time over the 100 cases, representing a gradual learning process. A marked decrease in the operative time for central compartment arthroscopy was noted when we compared group 1 (mean, seventy minutes; range, forty-five to ninety-eight minutes), group 2 (mean, forty-eight minutes; range, twenty-six to fifty-nine minutes), and group 3 (mean, thirty-seven minutes; range, eighteen to sixty-one minutes). The operative time for peripheral compartment arthroscopy also decreased from group 2 (mean, ninety-one minutes; range, sixty to 126 minutes) to group 3 (mean, forty-five minutes; range, thirty-six to sixty-two minutes). There was an overall decrease in operative time over the first 100 cases. No difference among groups was noted in the number of cases requiring a reoperation or conversion to arthroplasty. There was a higher complication rate in the first thirty cases. An increase in the nonarthritic hip scores was noted postoperatively in the two groups in which the preoperative score had been measured. The postoperative score improved from group 1 (mean, 69; range, 39 to 84) to group 2 (mean, 79; range, 58 to 92) to group 3 (mean, 86; range, 51 to 98). Patient satisfaction was highest in group 3. CONCLUSIONS Hip arthroscopy is associated with high patient satisfaction and good short-term outcomes, but there is a learning curve that we estimate to be approximately thirty cases.

Validation of the classification system for acetabular chondral lesions identified at arthroscopy in patients with femoroacetabular impingement

There have been considerable recent advances in the understanding and management of femoroacetabular impingement and associated labral and chondral pathology. We have developed a classification system for acetabular chondral lesions. In our system, we use the six acetabular zones previously described by Ilizaliturri et al. The cartilage is then graded on a scale of 0 to 4 as follows: grade 0, normal articular cartilage lesions; grade 1, softening or wave sign; grade 2, cleavage lesion; grade 3, delamination; and grade 4, exposed bone. The site of the lesion is further classed as A, B or C based on whether the lesion is less than one-third of the distance from the acetabular rim to the cotyloid fossa, one-third to two-thirds of the same distance and greater than two-thirds of the distance, respectively. In order to validate the classification system, six surgeons graded ten video recordings of hip arthroscopy. Our findings showed a high intra-observer reliability of the classification system with an intraclass correlation coefficient of 0.81 and a high interobserver reliability with an intraclass correlation coefficient of 0.88. We have developed a simple reproducible classification system for lesions of the acetabular cartilage, which it is hoped will allow standardised documentation to be made of damage to the articular cartilage, particularly that associated with femoroacetabular impingement.

Is the frog lateral plain radiograph a reliable predictor of the alpha angle in femoroacetabular impingement

The radiological evaluation of the anterolateral femoral head is an essential tool for the assessment of the cam type of femoroacetabular impingement. CT, MRI and frog lateral plain radiographs have all been suggested as imaging options for this type of lesion. The alpha angle is accepted as a reliable indicator of the cam type of impingement and may also be used as an assessment for the successful operative correction of the cam lesion. We studied the alpha angles of 32 consecutive patients with femoroacetabular impingement. The angle measured on frog lateral radiographs using templating tools was compared with that measured on CT scans in order to assess the reliability of the frog lateral view in analysing the alpha angle in cam impingement. A high interobserver reliability was noted for the assessment of the alpha angle on the frog lateral view with an intraclass correlation coefficient of 0.83. The mean alpha angle measured on the frog lateral view was 58.71 degrees (32 degrees to 83.3 degrees ) and that by CT was 65.11 degrees (30 degrees to 102 degrees ). A poor intraclass correlation coefficient (0.08) was noted between the measurements using the two systems. The frog lateral plain radiograph is not reliable for measuring the alpha angle. Various factors may be responsible for this such as the projection of the radiograph, the positioning of the patient and the quality of the image. CT may be necessary for accurate measurement of the alpha angle.

Review of evolution of tunnel position in anterior cruciate ligament reconstruction.

Anterior cruciate ligament (ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Other factors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Do physical diagnostic tests accurately detect meniscal tears

Thank you for your comment. We would like to congratulate Karachalios et al. [1] on the development of ‘The Thessaly Test’. This new test is user friendly and adds to the available array of diagnostic tests for detection of meniscus tears. While the points raised here are valid, they have already been discussed in our paper [2]. The fact that our study is a cohort study is evident from our methodology. The study was not designed to have a control group as a prospective randomized study. It was designed to assess a group of meniscal tears to see which tests were positive when there was a high likelihood that the test should be positive. The smaller study numbers and their effect on diagnosis in the presence of confounding knee injuries have been stated in the first paragraph of our discussion. The possibility of selection bias has also been addressed in our discussion. The study described by Karachalios et al. [1] was based on careful patient selection. The reality is that it does not reflect standard clinical practice. We have attempted the study in a clinical setting where patients may have confounding injuries. We believe that multiple factors have to be considered prior to the diagnosis of a meniscus tear. Various diagnostic tests and investigations help in the clinical decision analysis. They should be commended on a robust defense of their test but they should learn to accept its limitations. The sole use of any single diagnostic test as a selection tool for arthroscopic intervention cannot be supported based on currently available studies.

Joint Registries: A Ptolemaic model of data interpretation?

The National Joint Registry for England, Wales and Northern Ireland recently celebrated its tenth anniversary and has registered over a million operations. Along with other national registries, it now has a huge impact on the practice of joint arthroplasty worldwide. Registries realise the

A prospective comparative study of cementless total hip arthroplasty and hip resurfacing in patients under the age of 55 years: a ten-year follow-up

The aim of this study was to evaluate the ten-year clinical and functional outcome of hip resurfacing and to compare it with that of cementless hip arthroplasty in patients under the age of 55 years. Between 1999 and 2002, 80 patients were enrolled into the study: 24 were randomised (11 to hip resurfacing, 13 to total hip arthroplasty), 18 refused hip resurfacing and chose cementless total hip arthroplasty with a 32 mm bearing, and 38 insisted on resurfacing. The mean follow-up for all patients was 12.1 years (10 to 14). Patients were assessed clinically and radiologically at one year, five years and ten years. Outcome measures included EuroQol EQ5D, Oxford, Harris hip, University of California Los Angeles and University College Hospital functional scores. No differences were seen between the two groups in the Oxford or Harris hip scores or in the quality of life scores. Despite a similar aspiration to activity pre-operatively, a higher proportion of patients with a hip resurfacing were running and involved in sport and heavy manual labour after ten years. We found significantly higher function scores in patients who had undergone hip resurfacing than in those with a cementless hip arthroplasty at ten years. This suggests a functional advantage for hip resurfacing. There were no other attendant problems.

The direct anterior approach in total hip arthroplasty: a systematic review of the literature

Aims The most effective surgical approach for total hip arthroplasty (THA) remains controversial. The direct anterior approach may be associated with a reduced risk of dislocation, faster recovery, reduced pain and fewer surgical complications. This systematic review aims to evaluate the current evidence for the use of this approach in THA. Materials and Methods Following the Cochrane collaboration, an extensive literature search of PubMed, Medline, Embase and OvidSP was conducted. Randomised controlled trials, comparative studies, and cohort studies were included. Outcomes included the length of the incision, blood loss, operating time, length of stay, complications, and gait analysis. Results A total of 42 studies met the inclusion criteria. Most were of medium to low quality. There was no difference between the direct anterior, anterolateral or posterior approaches with regards to length of stay and gait analysis. Papers comparing the length of the incision found similar lengths compared with the lateral approach, and conflicting results when comparing the direct anterior and posterior approaches. Most studies found the mean operating time to be significantly longer when the direct anterior approach was used, with a steep learning curve reported by many. Many authors used validated scores including the Harris hip score, and the Western Ontario and McMaster Universities Arthritis Index. These mean scores were better following the use of the direct anterior approach for the first six weeks post‐operatively. Subsequently there was no difference between these scores and those for the posterior approach. Conclusion There is little evidence for improved kinematics or better long‐term outcomes following the use of the direct anterior approach for THA. There is a steep learning curve with similar rates of complications, length of stay and outcomes. Well‐designed, multi‐centre, prospective randomised controlled trials are required to provide evidence as to whether the direct anterior approach is better than the lateral or posterior approaches when undertaking THA.

Debridement versus re-attachment of acetabular labral tears A review of the literature and quantitative analysis

We have reviewed the current literature to compare the results of surgery aimed to repair or debride a damaged acetabular labrum. We identified 28 studies to be included in the review containing a total of 1631 hips in 1609 patients. Of these studies 12 reported a mean rate of good results of 82% (from 67% to 100%) for labral debridement. Of the 16 studies that reported a combination of debridement and re-attachment, five reported a comparative outcome for the two methods, four reported better results with re-attachment and one study did not find any significant difference in outcomes. Due to the heterogeneity of the studies it was not possible to perform a meta-analysis or draw accurate conclusions. Confounding factors in the studies include selection bias, use of historical controls and high rates of loss of follow-up. It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum on the other hand may be the source of discomfort and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears. Cite this article: Bone Joint J 2014;96-B:24–30.We have reviewed the current literature to compare the results of surgery aimed to repair or debride a damaged acetabular labrum. We identified 28 studies to be included in the review containing a total of 1631 hips in 1609 patients. Of these studies 12 reported a mean rate of good results of 82% (from 67% to 100%) for labral debridement. Of the 16 studies that reported a combination of debridement and re-attachment, five reported a comparative outcome for the two methods, four reported better results with re-attachment and one study did not find any significant difference in outcomes. Due to the heterogeneity of the studies it was not possible to perform a meta-analysis or draw accurate conclusions. Confounding factors in the studies include selection bias, use of historical controls and high rates of loss of follow-up. It seems logical to repair an unstable tear in a good quality labrum with good potential to heal in order potentially to preserve its physiological function. A degenerative labrum on the other hand may be the source of discomfort and its preservation may result in persistent pain and the added risk of failure of re-attachment. The results of the present study do not support routine refixation for all labral tears.

A performance based patient outcome score for active patients following total knee arthroplasty

OBJECTIVE The aim of this study was to develop and validate a user friendly performance based knee outcome score for use in active patients undergoing TKA surgery. DESIGN We prospectively studied a cohort of 50 subjects without any knee symptoms, and 50 patients who underwent TKA for osteoarthritis (OA). The patients were assessed pre- and postoperatively. SF-36 and WOMAC were concurrently administered for comparison. Patients completed seven physical tasks of the finalised outcome instrument which were objectively assessed and scored. RESULTS The mean functional score was 31.7 in the normal subjects. The mean functional score improved postoperatively from 10.0 to 17.7 (P < 0.001) in the TKA group. Our results confirm that the performance based score has a high test-retest reliability (intra-class correlation coefficient (ICC) of 0.89), internal consistency (Cronbachs alpha 0.84) and construct validity showing expected correlations with relevant components of the WOMAC and SF-36 scores. The responsiveness as measured by the effect size compared favourably with the same relevant components of the SF-36 and WOMAC. CONCLUSIONS Our performance based knee function score is a reliable dimension specific tool to detect change in musculoskeletal function after TKA. It complements existing self-reported outcome tools in facilitating a comprehensive assessment of patients following TKA.