Outcomes of Heterotopic Ossification Excision Following Revision Hip Arthroscopy
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1 Outcomes of Heterotopic Ossification Excision Following Revision Hip Arthroscopy John Redmond, MD Molly Keegan, MD Asheesh Gupta, MD, MPH Jacob Worsham, MD Jon Hammarstedt, BS Ammar Humayun, MBBS Benjamin Domb, MD
2 Disclosures American Hip Institute a, AANA Learning Center Committee a, Amplitude c, Arthrex b,c,d, ATI b, Breg b, DJO Global d, Orthomerica d, Pacira b,c, Stryker b,c a boardmember; b research support; c consulting; d royalty; e - stockholder
3 Background Heterotopic ossification (HO) is a known complication after hip arthroscopy, and its incidence has been reported in up to 44% of individuals who were not prescribed prophylaxis therapy Methods to reduce HO following hip surgery have historically involved postoperative radiation or chemoprophylaxis with nonsteroidal antiinflammatory drugs (NSAIDs) but HO still persists HO has the potential to be a pain generator and could affect patient negatively in the post-operative period. Performing an excision may improve the patients overall outcome.
4 Purpose To clinically evaluate patients undergoing revision surgery for HO excision via patient reported outcomes two years from surgery
5 Methods Study period: Retrospective review of prospectively collected data 2379 arthroscopic procedures around hip 68 (3%) had revision surgery for HO excision o >1cm HO ossification size, eliminated 45 patients o 23 (1%) met criteria for inclusion Two fellows assessed radiographs for inclusion Patient with previous hip conditions excluded: o Avascular Necrosis o Legg Calves-Perthes o Dysplasia
6 Patient Reported Outcomes (PROs) The protocol included pre and post operative administration of: o Modified Harris Hip Score (mhhs) o Non-Arthritic Hip Score (NAHS) o Hip Outcome Score Activities of Daily Living (HOS-ADL) Sports Specific Subscale (HOS-SSS) o Visual Analog Scale (VAS) o Satisfaction
7 Demographics Demographics Count 23 Follow-Up 15 THR 3 Outside Revision 1 Opted out of study 2 Lost To Follow Up 2 Follow-Up % 82.61% Mean Follow-Up Time (years) 1.52 Gender Male 10 Female 13 Laterality Left 12 Right 11 Age 38.66
8 Patient Reported Outcomes (PROs) Patient Outcome Score Reporting mhhs HOS ADLS HOS SSS NAHS VAS Satisfaction Pre Primary Pre HO Excision Lastest Post-Op Follow-Up T-Test T-Test Evaluation mhhs HOS ADLS HOS SSS NAHS VAS Pre Primary to Latest Pre Primary to Pre HO Excision Pre HO Excision to Latest
9 Patient Reported Outcomes (PRO) 23 patients had revision surgery and HO removal, 19 (83%) were available for follow-up at 1.5 years o Average scores prior to revision: mhhs 53.4, HOS-ADLS 51.4, HOS-SSS 24.5, NAHS 50.3, VAS 6.7 o Average score after revision with HO excision: mhhs 73.62, HOS-ADLS 68.88, HOS-SSS 58.51, NAHS 70.83, VAS 4.33 The majority had improvement in each category from before to after revision o Two (13%) patients had a decrease in the mhhs, two (13%) had a decrease in their HOS-ALDS, four (27%) had no change in their VAS, one (7%) had an increase in their VAS o Satisfaction scores varied from 0-10 with an average of 7.6 Out data indicates that the majority of patients will receive pain relieve (67%) from revision surgery with HO excision PROs improved in all categories, but the improvements fell short of good/excellent range o Only three patients had mhhs > 80
10 Patient Reported Outcomes (PROs) mhhs HOS - SSS Pre Surgery 1 Pre Surgery 2 Latest After Surgery 2 Pre Surgery 1 Pre Surgery 2 Latest After Surgery 2 HOS - ADLS NAHS Pre Surgery 1 Pre Surgery 2 Latest After Surgery 2 Pre Surgery 1 Pre Surgery 2 Latest After Surgery 2
11 Conclusions Patients undergoing revision hip surgery with HO excision demonstrated improved outcome scores and pain resolution; however, few patients achieved a good or excellent result. Conversion to THA or subsequent revision was seen in 21% of patients. Revision hip surgery with HO excision should be approached cautiously because of the modest results in this patient group.
12 References 1. Rath E, Sherman H, Sampsom TG, et al. The Incidence of Heterotopic Ossification in Hip Arthroscopy. Arthroscopy 2013; 29(3): Neal B, Harley G, MacMahon S, et al. Incidence of Heterotopic Bone Formation after Major Hip Surgery. ANZ J. Surg. 2002; 72: Kaplan FS, Glaser DL, Hebela N, et al. Heterotopic Ossification. JAAOS 2004; 12: Reichel LM, Salisbury E, Moustoukas MJ, et al. Molecular Mechanisms of Heterotopic Ossification. J Hand Surg Am 2014; 39: Rodenberg E, Azhdarinaia A, Lazard Z, et al. Matrix Metalloproteinase-9 is a Diagnostic Marker of Heterotopic Ossification in a Murine Model. Tissue Engineering 2011; 17: Bedi A, Zbeda RM, Bueno VF, et al. The Incidence of Hetertopic Ossification After Hip Arthroscopy. Am J Sports Med 2012; 40: Beckmann JT, Wylie JD, Kapron AL,et al. The Effect of NSAID Prophylaxis and Operative Variables on Heterotopic Ossification after Hip Arthroscopy. Am J Sports Med 2014; 42: Domb BG, Stake CE, Lindner D, et al. Revision Hip Preservation Surgery With Hip Arthroscopy: Clinical Outcomes. Arthroscopy 2014; 30: Harris WH. Traumatic Arthritis of the Hip after Dislocation and Acetabular Fractures: Treatment by Mold Arthroplasty. J Bone and Joint 1969; 51: Byrd JW, Jones, KS. Prospective Analysis of Hip Arthroscopy with 2 year Follow-up. Arthroscopy 2000; 16: Randelli F, Pierannunzii L, Banci L, et al. Heterotopic ossifications after arthroscopic management of FAI: the role of NSAID prophylaxis. J Orthopaed Traumatol 2010; 11: Cobb TK, Berry DJ, Wallrichs SL, et al. Functional Outcome of Excision of Heterotopic Ossification After THA. CORR 1999; Vasileiadis GI, Amantaullah DF, Crenshaw JR. Effect of Heterotopic Ossification on Hip Range of Motion and Clinical Outcome. J Arthroplasty 2015; 30:461-4
13 Conclusions Partial undersurface tears of the abductor tendons can be treated successfully with endoscopic transtendinous repair preserving the intact attachment of superficial fibers of the abductor Thank tendons. We you recommend this treatment for partial undersurface tears recalcitrant to non-operative treatment.
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