isha news© - international society for hip arthroscopy

ISHA NEWS©

AUGUST 2017

Contents

Editors Welcome Parminder J Singh

President’s Report Richard Field

ISHA Scientific Programme Chile Hal Martin

ISHA Host Chairman Report Rodrigo Mardones

ISHA Prizes Richard Villar

ISHA Book Joseph McCarthy

Journal of Hip Preservation Surgery Journal Richard Villar

Post publication Review Linkedin Ajay Malviya

Update on Joint Preserving Surgery Registry Vikas Khanduja

Update on ISHA physiotherapy Amir Takla

ISHA Research Report Hal Martin

ISHA Membership Report Tony Andrade

ISHA Education Secretary Report Paul Beuale

ISHA 2nd Travelling Fellowship Leandro Calil De Lazari

ISHA Website John Christoforetti

ISHA Articles – Twitter Derek Ochiai

ISHA Articles – Hip Arthroscopy in Melbourne John O’Donnell

ISHA Commentary – The Warwick Agreement Ian Harris

ISHA Articles Angular Deformity of the proximal Femur Robert Buly

ISHA Articles Cost Effectiveness of Hip Arthroscopy Olufemi R.Ayeni

ISHA Articles Does Hip Arthroscopy Prevent Total Hip

Replacement Vikas Khanduja

ISHA Articles Korean Society for Hip Arthroscopy Pilsung Kim

and Joint Preservation

ISHA Case Report A case of Diaphyseal Aclasia Josip Cakic

ISHA 2016 Annual Scientific Meeting Summary Al Stubbs

ISHA EDITORS WELCOME

Parminder J Singh

Welcome to ISHA NEWS 2017. This is our fourth edition of the

annual newsletter and I would like to express my thanks to the

editorial sub-committee Vikas Khanjuja, Addenbrooke’s,

Cambridge University Hospitals NHS Trust, UK and Associate

Professor Marcelo Queiroz from Santa Casa de São Paulo

Medical School, São Paulo, Brazil. In addition, a special thanks to

all the contributors of this year’s edition of the newsletter.

ISHA would like to thanks our current President Professor Richard Field for leading

the society through 2017. Professor Field discusses how new London hip surgeons

are expected to include arthroscopic hip surgery in their portfolio of surgical skills

and highlights the questions that still need to be answered in 2017 in hip joint

preservation surgery.

The ISHA Scientific Chairman Dr Hal Martin has been working hard on the 9th

Annual Scientific Meeting Programme that will showcase the best of ISHA through

an enlightening scientific program comprising comprehensive Instructional Course

Lectures, lively Presidential Debates, Concurrent Physiotherapy Sessions, and

Keynote Presentations. Dr Hal Martin has titled the meeting as “Preserving Hips

and Enhancing Life” and will aim to highlight the cost of hip disease to the

individual and to society during the annual scientific meeting.

ISHA would like to thank our host Chairman Dr Rodrigo Mardones for all of his

preparatory work for the forthcoming 2017 Annual Scientific Meeting. We are all

looking forward to visiting the city of Santiago. Dr Mardones has shared some of the

areas of his home city we can enjoy and also updates us on the growing interest in

joint preservation surgery in South America.

We hear from past ISHA President Dr Joseph McCarthy who is also one of the

editors the “Hip Joint Restoration: Worldwide Advances in Arthroscopy, Arthroplasty,

Osteotomy and Joint Preservation Surgery” book, on how we can get signed copies

of the ISHA Book authors at this year’s meeting.

Open access journals continue to have a positive impact on education. Some of the

advantages include journals are free to read and download. The Editor-in-Chief and

the first ISHA president Mr Richard Villar reports on the journal’s fourth year of

publication and how we all can continue to support the journal.

Modern day communication continues to take many forms. Mr Ajay Malviya

discusses how to get involved in the ISHA Linkedin group to facilitate communication

easy between hip preservation surgeons


The role of registries is beginning to influence orthopaedic practice around the world.

There are now 6500 procedure entered into the UK Non-Arthroplasty Hip Registry.

This year we hear from the new Chairman of the Steering Committee of the British

Non-Arthroplasty Hip Registry (NAHR) Mr Vikas Khanduja. Mr Khanduja discusses

how the Registry continues to develop in response to the feedback from its users

and the NAHR committee. Mr Khanduja provides a summary of the annual report.

This year we hear from Associate Professor Amir Takla on how the physiotherapy

group will run a meeting parallel to the surgeons. The physiotherapy group will offer

the opportunity for a practical morning instructional course to those individuals

looking at a detailed physical therapy assessment of complex hip conditions.

For the first time last year we heard from the Chairman of the ISHA Research

Committee Dr Hal Martin. Dr Martin this year will update us on a new book“

Diagnosis and Treatment of Posterior Hip Pain”; a project of predominantly ISHA

society authors.

This year our ISHA Membership Committee Chair Mr Tony Andrade update’s us all

on the latest figures of our membership numbers and how our society continues to

expand since our Annual Scientific Meeting in San Francisco in September 2016.

This year we hear more about the Korien Society Hip Arthroscopy and Joint

Preservation by Dr Pilsung Kim.

Professor Paul Beaule has completed his first year as the ISHA Education Secretary

and announces the two new traveling ISHA traveling fellows. For those who are

interested in the ISHA travelling Fellowship, please read the article carefully to obtain

the application rules for the fellowship.

ISHA news is proud to hear from ISHA’S 2nd travelling Fellow Dr Leandro Calil De

Lazari. Dr De Lazari provides a details account of his ISHA Fellowship learning from

some of the leading hip preservation surgeons around the world.

Dr John Christoforetti the chair of the ISHA Web Committee is proud to introduce a

newly renovated appearance and functionality to the ISHA website and updates us

on the first year of the new web design.

Dr Derek Ochiai for the first time discusses the role of Twitter in hip arthroscopy in

and your practice. Twitter currently has 313 million users. As many of you will be

aware, Twitter provides online news and social networking services where users

post and interact with messages, “tweets” restricted to 140 characters.

Next year in 2018, ISHA is proud to announce the 10th annual scientific will be held in Melbourne, Australia. On behalf of ISHA, Dr John O’Donnell invites all of you to the 10 year Anniversary of ISHA in Melbourne.


For the first time ISHA news provides a commentary on the much talked about Warwick Agreement paper on femoroacetabular impingement syndrome. Professor Ian Harris discusses some independent insights in this paper.

ISHA news is pleased to be able to reports on three hot topics this year including a review of angular deformities of the proximal femur by Dr Robert Buly; Cost Effectiveness of Hip Arthroscopy by Dr Olufemi R. Ayeni and Does Hip Arthroscopy Prevent Total Hip Replacement by Mr Vikas Khanduja. This year, we have a Case report from our incoming ISHA President, Dr Josip Cakic on “A Case of Diaphyseal Aclasia”. Finally, Dr Al Stubbs, the ISHA General Secretary and last year’s Scientific

Programme Chair summaries some of the highlights of the 2016 ISHA Annual

Scientific Meeting in San Francisco. ISHA news would welcome your feedback by

email to [email protected].

Parminder J Singh MB BS, MRCS, FRCS (Tr & Orth), MS, FRACS

Editorial Committee Chairman of ISHA

ISHA PRESIDENTS REPORT

Professor Richard Field

Twenty-three years ago, my colleagues encouraged me to set

up a hip arthroscopy service. It was the first in London and I

have never worked out whether their support was intended to

raise our hospital’s profile or to ensure that I would be labelled

as unsuitable for private hip referrals. Now, new London hip

surgeons are expected to include arthroscopic hip surgery in

their portfolio of surgical skills. On the face of it, I could claim

to have been ahead of the game. So, why am I still wary to be

called a hip arthroscopist?

For a start, I have an irrational fear that the pendulum might swing back to where we

were twenty-five years ago. In those days, hip arthroscopy was labelled as a

technique searching for an indication. But is that really possible?

Maybe! In the UK, arthroscopic knee surgery for early degenerative disease is now

a complete ‘no no’ and sub-acromial decompression of the shoulder may be

blacklisted before too long. Can we prove that our interventions are better than non-

surgical strategies? Do we really preserve natural hips and prolong their useful life?

Do our interventions really enable people to resume high-level sports when they

wouldn’t have been able to do so without our help? Can early intervention surgery

really stop hips from degenerating in the future?

These are questions that need to be answered. In my working life, hip preservation

surgeons have clearly demonstrated that peri-acetabular osteotomy changes the

natural history of dysplastic hips. Our mission is to gather and disseminate the

evidence that other hip preserving interventions (open or arthroscopic) are also

beneficial.

Discussion with friends over the past twelve months makes me hopeful that these

challenges are being addressed and I am excited to hear about the progress that the

hip preservation community is making during our forthcoming annual scientific

meeting in Chile. If you haven’t already registered for the ISHA 2017 Santiago

meeting, I urge you to do so and look forward to seeing you all in October.

Richard Field

Professor of Orthopaedic Surgery, St George’s University of London, Director of

Research, South West London Elective Orthopaedic Centre, Consultant Orthopaedic

Surgeon, Epsom & St Helier’s NHS Trust

ISHA Scientific Programme

Dr Hal Martin

ISHA Santiago De Chile, October 12-14 2017 is

approaching fast. The title of the meeting is

“Preserving Hips and Enhancing Life “. As hip

surgeons we impact the lives of our patients allowing

them to remain healthy, active and whole, not just fix

the hip technically. The cost of hip disease to the

individual and to society is not being recognized in

the way it should by health payment authorizes, nor are the contributions of our field

to understanding the anatomy, biomechanics, clinical or treatment modalities in the

critical role the hip plays in maintaining a healthy life or society. It is time the world

takes notice. For these reasons we will begin the first day with the cost of suffering to

the individual, family and society. The conference goals are to continue advancing

and meeting the needs of the organization as we move into the future understanding

normal and pathologic contribution of the hip to the entire human organism.

The Thursday we will begin together with the arthroscopic surgeons, physical

therapist, open surgeons and reconstructive surgeons (as many surgeons are

involved in all aspects in South America) sharing the advancements in the basics of

anatomy, biomechanics and clinical diagnostic techniques the goal of furthering the

common language of our field. The day will be full but not dense with time to discuss

and break for the numerous equally important corridor consults and discussion

important to our society and progress to our field. The posters will be in the corridor

and in the hope that both Friday and Thursday evening allows for reviews and

conversation, also a small competition is being organized.

Friday is going to be held in three rooms with instructional course lectures (ICLS) in

the morning. A paper presentation room will run simultaneous to the arthroscopic/

open hip symposium while the physical therapist host the closed treatment of hip

disorders section. With the rooms close we hope everyone gets to see and hear the

presentations most important to them.

The final day we will once again be together to discuss the future and exciting

directions of biologics, combine open and arthroscopic techniques, hip-spine disease

and cartilage. The business meeting will follow ending our time together on Saturday

afternoon. A cadaver skills lab will be hosted during the meeting.

Rodrigo Mardones is planning a robust program for the spouses and hope everyone

can plan to make it!

Golf, hiking and wine tours are under construction throughout the conference and

Sunday, when we can relax and join in all that Santiago has to offer!

ISHA Scientific Programme

If you have any insight or desire to help organize a section please email me at

[email protected]. The program will be finalized after abstracts submission

closes. Rodrigo, Anna Lozinska/Brown and I will be doing the organizational aspects

of the meeting.

We have a great story to tell about the history and achievement of this society.

Please, visit the ISHA web site for updates. I look forward to seeing you in Santiago

and wait with excitement receiving abstracts for the committee very soon!

Kindest regards and gratitude,

Hal

Hal David Martin MD

ISHA Program Chair 2017

mailto:[email protected]

ISHA Host Chairman Report

Dr Rodrigo Mardones

Welcome to Santiago

Everything you need to know about Chile!

The International Society of Hip Arthroscopy (ISHA) is proud to announce the 2017 annual scientific meeting will be hosted in Chile, South America. The number of member joining ISHA and academic participants during the meeting has gained

momentum and has been increasing year by year There continues to be growing interest in joint preservation surgery in South America. The Scientific meetings on hip arthroscopy have grown significantly over the last three years. Santiago held the first Latin American meeting kindly sponsored by Smith & Nephew in 2015, followed by Sao Paulo Puerto Rico. In May 2016 another hip arthroscopy meeting was held in Cartagena De Indias (Colombia) with over 200 delegates attending. In July 2016, SLARD and the Association of Argentina de Artroscopia held their annual meeting in Buenos Aires with increasing time spent discussing hip arthroscopy and relating issues. There is no doubt that the practice number of surgeries and scientific meeting is still growing in Latino-America. Cadaver laboratory training has been featuring in most of our countries providing a valuable adjunct to education in hip arthroscopy in South America. Chile, is a destination that attracts for its diversity and vitality. Throughout its narrow

fifteen regions you can discover spectacular landscapes among the driest desert in

the world, eternal ice, humid forests, vibrant cities and picturesque altiplano villages.

Its elongated form gives rise to a wide variety of climates and landscapes, from the

driest desert in the world in the extreme north, to the eternal ice of the southern end.

Between these two radical scenarios, an astonishing variety of ecosystems come

alive, which generally remain arid to the north and greener to the south. Also from

the east to the west, the landscapes change radically, passing from the enormous

peaks of the Andes mountain range in the east, to the beaches bathed by the Pacific

Ocean in the west.

Among its varied geography, its main tourist destinations are related to its extreme

areas. In the north, Chungará Lake and Parinacota volcano, San Pedro de Atacama,

the high plateau lagoons and the El Tatio geyser field, considered the largest in the

southern hemisphere and the third on the planet, are highlighted

On the other hand, in the south, the Vicente Pérez Rosales National Park, the Chiloé

archipelago, the Patagonia, the San Rafael Lagoon and the Torres del Paine


National Park stand out. Other famous tourist sites correspond to Easter Island,

located in the Pacific Ocean, and numerous international ski resorts in the Andes.

It is one of the most peaceful countries in South America, ranking among the nations

of the region with the lowest rates of serious crimes according to the report of the

Institute for Economics & Peace's Global Peace Index 2015.

Wines and Gastronomy

Foods that fuse with traditional preparations marked by the identity of ancestral

villages, give rise to a varied gastronomic offer of a unique character. Let yourself be

captivated by the intense flavors that come from both the land and the Chilean sea.

Enjoy the quinoa-rich dishes offered by northern cultures and lands; And be amazed

by the tropical fruits that you will find in fertile valleys in the middle of the desert.

In central Chile, soak up by the peasant traditions by tasting the classic empanadas

or corn preparations like the pastel de choclo(corn cake) and humitas. And refresh

with a delicious mote con huesillos, cold juice and caramel, ideal for hot days.

Fish and seafood are the unquestionable protagonists of the extensive Chilean

coast. Conger caldillo, parmesan mussels and oysters at pil pil are just some of the

favorite dishes for lovers of seafood.

In the south of Chile, marvel yourself with the cazuelas(type of soup) and tortillas of

mapuche cuisine. In Chiloé, surprise yourself with the preparation of curanto,

cooking of seafood, meats and potatoes that is prepared directly in a hole in the

ground. And if Patagonia is your destination, do not forget to try the coveted

southern crab and the famous Magallanic lamb prepared "on the stick."

Natural reserves

Discover the forests and dozens of unique environments considered State Protected

Wild Areas. Walk, ride or bike these places.

In total, the protected zones in Chilean soil reach 20% of the extensive national

territory. Between the sea and the mountain range, from the driest desert in the

world to the Patagonian glaciers, there is an immense natural wealth that fascinates

those who admire nature and outdoor life.

You can camp listening to the water falling from the waterfalls and wake up with the

singing of various species of birds. Walk in among millenary trees and observ a great

variety of animals. From small foxes and vizcachas to giant whales will witness your

journey through the country.


Patrimony of Humanity

The immensity of the Chilean territory welcomes unique places of exceptional natural

importance. Its importance is such that in order to make them known and preserved

for future generations, UNESCO declared them as Patrimony of Humanity. These

are: Humberstone and Santa Laura Salitreras Offices, Rapa Nui National Park,

Valparaíso Historic District, Churches of Chiloé and Sewell City, a mining town.

What to do in Santiago?

Dynamic and cosmopolitan, Santiago, captivates by its diverse outlook and that

versatility that characterizes it. Stage of events that highlight the Chilean culture and

great international festivals, through their sounds, flavors and colors. The Chilean

capital is full of life to all who visit.

Diversity can be felt in their neighbourhoods; travel them is the best way to know the

city. Lose yourself in the streets to find original art galleries, innovative design shops

and craft fairs, as well as restaurants, bars and cafes, which complements with an

attractive and novel offer. And if you are one of those who love the night, do not miss

the nightlife of Barrio Bellavista!

Visit the old centre of the city. You can learn more about Chile in the many museums

or take a tour of the famous Central Market to taste the exquisite products of Chilean

gastronomy. To enjoy a panoramic view of the city, climb to the top of San Cristóbal

hill by bicycle or cable car, or ascend to the Sky Costanera, the highest viewpoint in

Latin America.

If your life is outdoors, admire the capital from the surrounding hills and marvel with

the views of Santiago at the foot of the imposing Andes Mountains and take

advantage of a picnic in one of the parks in the city.

To go shopping do not miss the elegant neighbourhood Alonso de Cordoba, and the

many modern shopping centres of the city.

Do not miss the opportunity to know this amazing country, Chile awaits you!

SAVE THE DATE

On our website you can find all the tour offers to know Santiago, or some of the

regions and places of interest.

Also on the website you will find all participating hotels in ISHA 2017.

www.ishameetings.cl

http://www.ishameetings.cl/

ISHA Hip Joint Restoration Book

Dr Joseph McCarthy

Hip Joint Restoration: Worldwide Advances in

Arthroscopy, Arthroplasty, Osteotomy and Joint

Preservation Surgery is now in production by Springer.

Signed copies of the book will be available for the

forthcoming ISHA 2017 annual scientific meeting in Santiago.

There will also be the opportunity to take photographs with

the senior authors.

Best regards, Joe

ISHA PRIZES

The Richard Villar Trainee Excellence in Clinical Research Award

The prize was awarded to Dr Shruti Raut (UK) in San Francisco for her research on

“Labral Tears in Young Sexually Active Women: An Evaluation of Patient

Satisfaction After Hip Arthroscopy”

The Richard Villar Society award for outstanding contribution in hip preservation 2016 The prize was awarded to Dr James Glick (USA) in San Francisco

ISHA Trainee Basic Research Award

The prize was awarded to Dr Juan Gomez Hoyos (Colombia) in San Francisco on

his research on the “Influence of Aging on Microvascular Supply of the Gluteus

Medius Tendon”

Joseph McCarthy Award

The prize was awarded to Dr Marc Phillipon (USA) in San Francisco

Journal of Hip Preservation Surgery

Richard Villar

What a year!

What a year! It seems like only yesterday I was planning a

report on the Journal of Hip Preservation Surgery (JHPS)

for the last ISHA Newsletter. Here am I, doing the same

once more and, dare I say it, enjoying every moment.

You see the journal, our journal, is performing brilliantly.

That is despite a huge reorganisation of Open Access at

Oxford University Press. The journal is now in its fourth year of publication and still

going strong. OUP likes us, we like OUP, and the papers are still tumbling in. From

time to time we perhaps take a little longer assessing a paper than we ought,

although in keeping with most journals it is almost unheard of for a submission to be

accepted on first review. Behind the scenes, debate between the editors - me, Marc,

Phil, Michael - is frequently fast and furious, so as Editor-in-Chief I am often judge

and jury. So, what is the reasoning behind accepting a submission? Believe me

when I say the reasoning will vary from paper to paper.

You may, for example, have decided to submit in a subject area that has already

been widely published. That is fine as, to some extent, the more the merrier.

However, when your paper is competing with so many others, there must be

something special about it. It must also be scientifically sound. That does not mean

your submission should be the fruit of a Level 1 study, far from it, but it must still be

sufficiently robust scientifically to withstand the scrutiny of review.

And reviews. If there is one thing I can highlight about JHPS, it is the standard of

review. It is more than good, should there be such a word. Over two decades of

journal editing, in several guises, I have seen many different standards of review.

There are some top-end journals, household names, which struggle to find decent

reviewers in the field of hip preservation. Some of the reviews for these journals

have, in my view, been an embarrassment.

But for JHPS we are blessed by what I regard as the best hip preservation reviewers

on the planet. These colleagues are busy enough as it is, without adding our reviews

to their remit. Somehow, they still do it, spend whatever time it takes to assess a

paper, and offer not only a decision as to whether a paper should be accepted,

revised or rejected, but can also suggest how a submission might be improved. How

many other journals can offer that? A submission improved thanks to the advice of a

world-leading figure. Not many, I would wager.


This is especially important in our multilingual world, where English is, for many, not

a first language. Our aim is for a JHPS review to be a treasure, something an author

would be proud to show others. Mostly we succeed, and it is thanks to the reviewer

team, each one a colleague I regard as a friend, that we can do this. Thank you,

reviewers. I have said it before, I say it again, but JHPS would simply not exist

without you. There are enough journals crumbling into extinction but JHPS is not one

of them. Thank you, thank you, thank you, from the bottom of my heart.

The review process, excellent though it is, does not always identify the high-flying

paper. There are some submissions we have rejected that I see subsequently in

other journals. I beg forgiveness from the authors that we did not recognise the worth

of their work. Yet there are also papers that scored low on submission, sneaked past

review by a thread, and subsequently scored highly with pdf downloads and

citations. Scientific accuracy, it appears, does not always mean a submission will be

accepted. Occasionally a degree of inaccuracy can be ignored, as the topic is likely

of great interest to others and can act as a stimulus for others to develop their

research. What any editor seeks is a paper that will be debated, discussed, and

analysed by a readership. Papers are not always about giving answers; they may

also give ideas.

PubMed has been a slight worry this year as several authors have made contact to

say their papers have not appeared on PubMed as they had expected. This is true

but I know that OUP is pedalling furiously to rectify the situation. The way PubMed

works is that a publisher must present their papers in a certain way, thereby

permitting PubMed to lift them onto their system. However, OUP changed its website

in the early part of 2017, a shift that led to PubMed appearance being delayed for

some. I cannot pretend to properly understand the geek-speak, but I have been

assured all will soon be in control. However, if you have been published in JHPS,

particularly recently, I would beg you to look at PubMed and be sure that you

rightfully appear. If you do not, please let the editorial team know and we will press

the appropriate button.

So, thank you for your ongoing loyalty to JHPS, a loyalty I regard as invaluable and

irreplaceable. Keep those papers coming and we will give them a fair hearing. And if

you have any ideas, irrespective of topic, send them our way. I assure you of our

fullest attention. None of us would have guessed at the start that our journal would

be going so strongly four years after inception, especially with so many other

publications failing. In the world of Open Access, there is decimation out there. A duff

journal will not last for long. But JHPS? Go for it. JHPS has made it, has maintained

it and is a point of pride for many. Much of this, perhaps all of this, is very largely

thanks to you.


My very best wishes to you all.

Richard (Ricky) Villar

Editor-in-Chief



Mr Ajay Malviya

Journal of Hip Preservation Surgery – Linkedin group

Social media has revolutionised communication; in this world of

twitter, linkedin, instagram, snapchat, whatsapp, while perhaps

most feel the burden of being in too many groups on various

fora, there are benefits in being involved in at least some. Can I

just remind the membership of the linkedin group

(https://www.linkedin.com/groups/8404946) primarily formed for making

communication easy between hip preservation surgeons? How many times have we

seen an article and need further clarification but can’t be bothered to write a formal

letter to the authors via the editor? Wouldn’t it be easier if it can happen via this

group if authors, editors and readers all become members? Apart from discussing

interesting articles it can be used as a message board for important courses,

fellowships, case discussions, video or surgical tips and tricks; the potential is

immense. It is a closed group, so only members can access the information and

reasonable privacy is maintained. Currently we have just over fifty members but with

the help of the ISHA membership the group can grow further.

Can I also remind you of the “What the papers say” section of the Journal of Hip

Preservation Surgery? It attempts to provide a summary of all published research on

hip preservation. The papers included are the one that are published within three to

four months of writing the article. There are various criteria for selection, while

scientific content is paramount the findings should also be of interest to the

readership. As you can appreciate large number of high quality papers are published

and not all can be quoted, which may feel slightly unfair to some authors, but our

attempt is to provide a global representation. Overall the intention is to make the

readership aware of what is going on in the field in various corners of the world.

Ajay Malviya PhD, FRCS T&O, MSc, MRCSEd, MS T&O

Honorary Senior Lecturer Newcastle University, Consultant Orthopaedic Surgeon

Northumbria Healthcare NHS Foundation Trust, UK

https://www.linkedin.com/groups/8404946

Update on the British Hip Society’s Non Arthroplasty Hip Registry (NAHR)

Vikas Khanduja (Consultant Orthopedic Surgeon) , Naoki Nakano – (Research Fellow) Department of Trauma and Orthopaedics, Addenbrooke's - Cambridge University Hospitals NHS Foundation Trust The National Institute for Health and Clinical Excellence (NICE) in the UK published guidance on open and arthroscopic femoro-acetabular surgery for hip impingement in 2011, which recommended inclusion of this type of surgery into a non-arthroplasty hip register. In response, the NAHR was launched at the Annual General Meeting of the British

Hip Society (BHS) in 2012, and it continues to develop in response to the feedback from its users and the NAHR committee. The results of hip replacements are already captured on the National Joint Registry (NJR) and the main focus of the British Hip Society in setting up the NAHR was to monitor the outcome for patients undergoing non arthroplasty surgery of the hip and to further improve the quality of hip surgery in the UK.

Since its introduction, the NAHR has been refined continuously and data entry has been simplified, being aligned to all the other registry’s in the UK. Surgeons conducting this type of hip surgery enter data, and patients are then contacted for information about their progress via e-mail at regular intervals post-operatively. Cases from both the National Health Service (NHS) and the independent sector are included in the NAHR.

The register at its latest count includes the data of over 6500 procedures and continues to grow. However, issues of surgeon and patient engagement remain and the NAHR sub-committee is working tirelessly to address this issue.

Summary of the NAHR 2016 Annual Report

Patients’ age distribution


84% of cases entered on the NAHR were between the ages of 15 and 50 years and 48% were between the ages of 20 and 40 years.

Gender distribution - Of those patients undergoing hip arthroscopy, 60% were female compared to 80% of patients undergoing open procedures. This may represent the higher incidence of acetabular dysplasia in women and their consequent treatment with open procedures (peri-acetabular osteotomy).

Surgical findings at arthroscopy

The largest single finding was labral tear. Labral tears and chondral defects were also common and a small number of ligamentum teres ruptures were recorded.


Surgical procedures: In acetabular procedures, labral debridement is the most commonly performed acetabular procedure in arthroscopic surgery. In femoral procedures, cam removal accounted for the largest proportion of procedures with no difference in the rate between arthroscopic and open approaches.


The EQ-5D index score is based on five domains (mobility, self-care, usual activities, pain/discomfort and anxiety/depression) each with five options (no problems, slight problems, moderate problems, severe problems and extreme problems).

EQ-5D VAS: The EQ Visual Analogue

score records the respondent’s self-rated health on a 20cm vertical scale where endpoints are labelled ‘Best imaginable health state’ (100 points) and ‘Worst imaginable health state’ (0 points).

iHOT-12: This is a short form equivalent of the International Hip Outcome Tool-33 (iHOT-33), and this shorter version demonstrates excellent agreement with the long version.

There does seem to be a trend towards improvement in all three of the mandatory scores. Also, there is a suggestion that the outcome of hip arthroscopic procedures continues to improve out to two years while the outcome of open procedures at two years deteriorates to pre-operative levels.


Labral repair vs. labral debridement: Although some studies have shown better outcomes in labral repair and preservation, these studies have not been randomised trials and selection bias makes interpretation difficult. From the NAHR, pre-operative scores between the three groups (labral repair, labral debridement, and those recorded as having both techniques) are similar and there is a trend towards improvement out to one year with no clear difference between the three treatment groups.


Acetabular procedures - Rim Recession :Regarding acetabular rim recession, the NAHR records this as either complex, involving labral reattachment or simple, which would include retro-labral rim recession, leaving the chondro-labral junction intact or rim recession of a calcified labrum with no clear labrum to detach. The EQ-5D Index is similar pre-operatively between the two groups. Post-operatively, out to two years, there is a trend towards improvement with no obvious difference between the two groups. The EQ-5D VAS is similar between the two groups but does not show the same trend towards improvement and seems to remain fairly static even out to two years. The iHOT-12 shows similar pre-operative scores and a trend

towards improvement post-operatively. The iHOT-12 at two years for simple rim recession without reattachment appears to decline to pre-operative levels at two

years.

Femoral procedures :Femoral procedures are categorised into five domains: cam removal alone; osteophyte removal; cartilage debridement; cam and osteophyte removal; and cam removal and cartilage debridement. There is no clear difference in the pre-operative scores for the groups, and there is a trend towards improvement at six months.


In the near future, larger numbers of pathways and follow-up scores, which will allow some statistical analysis to add to our knowledge of the success of different surgical approaches and surgical techniques are needed.

For more information about the NAHR, please visit https://www.britishhipsociety.com/main?page=NAHR

Vikas Khanduja

Consultant Orthopaedic and Trauma Surgeon

Addenbrooke’s Hospital, Cambridge University Hospitals NHS Trust, UK

https://www.britishhipsociety.com/main?page=NAHR

ISHA Physiotherapy Group Progress Report

Associate Professor Amir Takla

Following the successful introduction of the concurrent Physiotherapy program three years ago in Rio and more recently, the well-attended program in San Francisco 2016, we are delighted to report that the academic physiotherapy program for Santiago 2017 is taking shape. As in previous years, the Annual Scientific Meeting will run over three days with the first day of the congress having a parallel physiotherapy meeting.

On the first day of the Congress, the physiotherapy group will run a meeting parallel to the surgeons, solely for physiotherapists and sports medicine delegates. We are delighted to be able to offer the opportunity for a practical morning instructional course looking at a detailed physical therapy assessment of complex hip conditions. These presentations will focus upon the diagnostic process and decision making in the non-operative to operative to post-operative management of patients with various hip pathologies. We are excited to announce that renowned international physiotherapists Mike Voight, Amir Takla Ashley Campbell, Robroy Martin, Keelan Enseki, Tim Tyler, Michael Rafla, Barry Getz amongst other talented and published physiotherapists have already agreed to speak

The programming at ISHA 2017 will be completely integrated between surgeons and physical therapists over the three day conference. Thursday and Saturday will be joint meetings addressing topics of interest to both surgeon and physical therapists. Friday will be a specialty breakout day, which will include a full day physical therapy specific presentations entitled “Beyond Labral Tears”. Topics will include posterior hip pain, instability, extra-articular conditions, post-operative conditions, and physiotherapy- Chile perspective. The entire conference will be organized to allow plenty of professional dialog in the form of round table discussions and patient presentations.

The physiotherapy group now faces the significant challenge of marketing and spreading the news of our program to attract delegates and we look forward to the support of the APTA and Sports Physical Therapy Section. In addition to our targeted advertising plan, we ask our surgical readers to inform their physiotherapy and sports medicine colleagues about this year’s ISHA conference by directing them to the ISHA website or putting them in touch with one of our team.

The Physiotherapy Group’s primary goals are to bring together bright minds in physiotherapy and sports medicine to share new research, discuss current topics and present evidence based practice. We look forward to contributing to a stimulating academic program in Santiago this year that will foster learning, discussion and inspiration.

See you in Santiago, Chile.

ISHA Physiotherapy Group Progress Report

A/Prof. Amir Takla B.Physio, Mast. Physio. (Musculoskeletal) Sports & Musculoskeletal Physiotherapist, MAPA, MMACP (AUS) [email protected]

Professor Mike Voight PT, DHSc, SCS, OCS, ATC, CSCS, FAPTA. Professor – Belmont University School of PT, [email protected]

Professor RobRoy Martin – PHD, BS PT, Professor – Dequesne University school of PT, [email protected]


ISHA Research Report

Dr Hal Martin

Research grant guidelines were proposed in San Francisco which is under revision by the committee. It will be a big help to have a program for financing key projects, which has been a significant problem in several translational and basic scientific ISHA efforts. The goal of obtaining a non-industry supported combine registry is also once again being considered.

The sub-committee efforts have been negatively impacted by this financial obstacle and how best to fund independently.

We have many fantastic sub-committee leaders with wonderful ideas just waiting to get this resolved and hopefully will be achieved by Santiago.

The book“ Diagnosis and Treatment of Posterior Hip Pain” is nearing its completion as a project of dominantly ISHA society authors and hopefully out by the end of the year slightly behind schedule. I appreciate all the help with this project and hope it will help bring light to this complex pathology.

It would be fantastic if the sub-committee chairs could organize their teams and coordinate a time together at the meeting. Please, let me know how best to help.

I excitedly look forward to seeing you and your research efforts very soon!!

Kindest regards,

Hal

Hal Martin, Chairman of the ISHA Research Committee

ISHA Membership Secretariat Report

Tony Andrade

We are pleased to report that our membership numbers have

continued to expand since our Annual Scientific Meeting in San

Francisco in September 2016.

We now have 534 members (497 at the time of the San

Francisco AGM):

465 Ordinary members

46 Associate members

19 Affiliate members

4 Emeritus members

Our membership now spans 42 different countries

The Geographical distribution of these members is:

ISHA membership Secretariat Report


There have been 42 new membership applications since the San Francisco AGM

in 2016. These are to be ratified at the AGM in Santiago where the full list of these

names will be available.

The Website:

The www.isha.net website has gone through some further updates with lots of new

features! Please check it out, you will love it….

Action requested of all members:

1- Please log in to the members area on the website and check if you have any new member applications to verify.

There are 80 new membership applications awaiting verification, as of the 10th

July 2017.

2- Please also check your personal details on your “view my profile” page, and ensure

a. Your address is shown correctly (including country).

Please remember that the address displayed is the one that will be used in the “find

a surgeon” search by patients or other healthcare professionals. The geographical

details are used for the “find-a-surgeon” feature on the website, and so it is important

that these details are correct.

b. Your email is correct.

Do please notify any change in email address immediately as this is our primary

means of communication with you. Please amend all the details as necessary.

Please, please, check all your details as currently there are many inaccuracies

which affect our ability to extract information about geographical distribution of

members. We estimate there is data is missing on up to 5% of our members.

http://www.isha.net/


Membership Fees:

We are sorry to report that there have been some further issues with the Paypal

function on the website, and we apologise to all members who have been

inconvenienced by this.

We would however request that all members who have set up a recurring payment

through Paypal please ensure that they have set the payment date for June. If you

have not done so, please change the date to June to avoid duplication of payments.

NON-PAYERS:

There are currently:

146 members who are yet to pay their 2017/18 membership fees.

393 paid up members for 2017/18.

A repeat cycle of reminder letters has been sent to the non-payers. The ISHA office

will continue to chase these, so please respond and pay!

ISHA Ties and Scarves:

We are pleased to announce that the ISHA membership tie (and scarf for the

ladies) continues to be available. As a paid-up member you are entitled to one so if

you are yet to collect one (and your membership payment is up to date) please

collect it from the ISHA booth at the Annual Scientific Meeting in Santiago. If you

would prefer it to be mailed to you, please contact the ISHA office for details of

postage and packing costs

Lastly, we welcome any feedback, suggestions or comments on how we can

improve things for you.

We look forward to seeing you all in Santiago!!

Tony

Tony Andrade, MB BS, MSc, FRCS (Tr & Orth)

ISHA membership Secretary

ISHA Education Committee Report

Professor Paul Beaule

At ISHA’s annual meeting in San Francisco, the board held a

one-day executive meeting. In regards to Education, Smith-

Nephew continues to be engaged in supporting our traveling

fellowship. We continue to develop relationships with our sister

associations as well as new means to

I would like to thank the members of our Committee for their

continued support and contributions: Damian Griffin from

Warwick, UK; Michael Dienst, Germany; Nicholas Bonin, France, Dean Matsuda,

USA and Chuck Cakic, South Africa

In San Francisco our traveling fellows presented their experience with Leandro Calil

De Lazari, MD, Ph.D, Chief of Orthopaedic Institute at Hospital Santa Casa –São

Paulo, Brazil and Mr. Justin Nicholas de Beer from Ballito, South Africa.

Our two new traveling ISHA traveling fellows were selected and we are pleased to

announce that this year’s recipients are: Dr. Sasha Carsen from the Children’s

Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada and Dr Michael

Van Niekerk from Whangarei Hospital, New Zealand

To remind everyone, there are the rules of the Fellowship:

APPLICATION REQUIREMENTS

1. Applicants must be members of ISHA.

2. Applicants must have completed an Orthopaedic surgery residency, be Board Eligible or have an equivalent Degree in Orthopaedic Surgery.

3. Applicants should have knowledge in arthroscopic surgery with interest in hip arthroscopy and be familiar with hip pathologies and treatments.

4. Applicants should speak English, be able to present, articulate their experience, and have experience in academic presentations. Applicants have to be prepared to present and publish their fellowship experience.

5. Applicants are required to submit a short essay (300 words or less), the letter of proposal and their curriculum vitae. The essay should explain their interest in the hip arthroscopy, what they would like to learn during the fellowship, and their academic and teaching goals when they return to their country. Applicants must be able to afford 2 months away from daily routine work obligations.

The Hip Arthroscopy Travelling Fellowship will consist of three parts:

ISHA Education Committee Report

Part one will take place in the respective Country or Region from where the fellow is coming. This part of the fellowship will consist of practical training with a local

Consultant- Mentor chosen by ISHA Board. In this part of the fellowship, the fellow surgeon will be introduced to basic, intermediate and advanced techniques of hip arthroscopy, depending on the starting level defined on the interview and checked by the mentor. This part of the fellowship should take up the first 6 weeks. During this time, if circumstances will allow, the Fellow should be exposed to a cadaver workshop as well.

Second part of the Fellowship should be taken place 4 weeks before the Annual ISHA Meeting. During that month, the Fellow will be visiting 2-3 International experts in the field of hip arthroscopy. During that time the Fellow will be able to observe surgery, be involved in pre-operative as well post-operative clinical work.

Final round of the Fellowship will be at the Annual Meeting. Fellows must document their travels, write a report of the experience to present at the ISHA Meeting, as well as, submission for possible publication at the ISHA website/Newsletter. The Fellow should be prepared to present their experience of the fellowship as a 10 min “Traveling Fellowship Breakdown – Year ....”.

REVIEW PROCESS

Applications will be reviewed, if found necessary, candidates will be interviewed and best applicants will be selected by representatives of the ISHA General Board, and the final decision ratified by the Executive Board. Preference will be given to those who have demonstrated significant interest in hip arthroscopy and are passionate to spread the knowledge they gain upon return to their respective countries. The final Review Process and decision of two Fellows for the following calendar year will take in December of the preceding year of travel.

I would like to take this opportunity to encourage ISHA members to apply to the ISHA Travelling Fellowship, to embrace this opportunity to be able to work with world experts in the field of hip arthroscopy. Also, I would like to express my gratitude to Smith & Nephew who made all of this possible with their generous Education Grant.

Applications for the Smith & Nephew - ISHA International Traveling Fellowship should be submitted directly to ISHA office: [email protected] . DEADLINE is December 15 2016.

Sincerely,

Paul E. Beaulé MD FRCSC

Chair of the Education Committee

ISHA Travelling Fellowship

Leandro Calil De Lazari, MD, PhD

Brazil

My Experience

I have been an orthopedist since 2001 specializing in knee and

hip surgery. I currently coordinate the orthopedic services for

the São Lucas and Ribeirania Hospitals in Ribeirão Preto, São

Paulo, Brazil, and I am also responsible for the orthopedic

residency for the Ribeirão Preto Medical School/ Universidade

de São Paulo (FMRP / USP) in Santa Casa Hospital.

My interest in hip arthroscopy started in 2011 where I began studying the technique,

participating in bio-skills laboratory in the USA (2012, 2013 and 2014) and visiting

reference services such as the Steadman Philippon Research Institute and Nashville

Sports Medicine & Orthopedic Center. In Brazil, I learned a lot about general hip

surgery with Prof. Dr. Celso Picado (FMRP / USP), and with Prof. Dr. Giancarlo

Polesello (Hospital Santa Casa de São Paulo) I had the opportunity to know and

learn about hip arthroscopy technique.

During those years I began to perform arthroscopic procedures in my city and region,

and I made steady progress. I realized that I needed to immerse myself in more

complex procedures, surgical revisions and to update myself in new techniques, so I

signed up for ISHA Traveling Fellowship in 2015. I had the honor to be accepted for

the 2016 Fellowship, which opened the doors for Brazilians in this surprising

academic experience.I chose my mentors based on the areas of interest I would like

to learn more about.

In April I went to Vail to visit Dr Philippon, my interest was in the surgical revision,

reconstruction and suture of the labrum and joint capsule. This research center is

one of the most complete I have ever visited, and Dr Philippon is always very

innovative and dedicated in the development of his research and surgical

techniques. I had the opportunity to observe several surgical procedures, to discuss

cases and to participate actively in the bio-skills laboratory, where I practiced in

cadaver the techniques learned in the surgical room. I made friends with doctors

from various countries, visited some places in the Vail area, and of course I went

skiing.

In May I went to Munich to visit Dr Michael Dienst. My goal was to learn more about

the extra compartmental technique (no traction). I learned many tricks about this

technique, which starts without traction, and then the intra-compartmental


procedures are performed. It was interesting to learn more about medicine in

Germany, also the efficiency and objectivity of the German method of hip

arthroscopy. Of course, I had the opportunity to see magnificent places in Munich

and Bavaria, as well as enjoying good beer and tasting local food.

In July I went to Dallas to visit Dr Hal Martin. I intended to learn about deep gluteal

pain, which I did. On top of that I learned a lot about hip spine syndrome, peri

articular endoscopy, labrum suture without traction and several other techniques. I

was grateful to participate in his medical appointments, and was admired to see his

dedication in examining his patients, in the search for the correct diagnosis. I also

had the opportunity to make good friends and to get to know the grandeur of Dallas

and Texas.

Then I went to Nashville to visit Dr Thomas Byrd. I looked for an update on the

concepts and techniques of labrum repair, surgical revision, exams and clinical

diagnoses. Dr Byrd is always a great gentleman, he welcomed me with open arms

and I was able to participate in various procedures and medical appointments. And

of course, I enjoyed the traditional country music.

In general, I had activities such as hip arthroscopies, open surgeries, medical

infiltration, medical appointments, physical examination, pre and post operatory,

physiotherapy, scientific paper meetings, clinical cases discussions, surgical

techniques discussions, bio-skills laboratory.

But a part of the academic activities, I have been able to strengthen the bonds of

friendship with these mentors and their staff, to know new places and different

cultures, and to show a little of the culture of my country.

I am very grateful to ISHA, its directors, and of course my mentors. I am thankful for

the grant that I received, which helped me with the cost of traveling. I also would like

to thank the attention that Dr Paul Beaule (ISHA Education Committee) and Anna

(ISHA Secretary) gave me.

I was kindly received as a friend everywhere that I visited and I realized there

interest in showing me all the cases, the inherent difficulties of which procedures, the

surgical techniques and their skills. I was very honored to be part of those teams,

even for a short time.

In my opinion, this fellowship serves all levels of training and all phases of the

orthopedist's career. I have 15 years of knee and hip surgery, 5 years of hip

arthroscopy, and I can surely say that I learned new concepts, new techniques and

the tricks and tips of great masters. Nowadays my patients benefit from the collective


knowledge and techniques I learned with Dr Philippon, Dr Dienst, Dr Hal Martin, and

Dr Byrd.

Enjoy this opportunity!!!

Leandro Calil De Lazari, MD, PhD

[email protected], www.leandrocalil.com.br


http://www.leandrocalil.com.br/

ISHA Web/Tech Committee Report

Dr John J Christoforetti Communications committee update: This year marks the first year of your new web design. Please sign in and use the site! The hip icon allows all members to select ISHA committees, and send emails directly to the committee chairs- suggestions, comments, or VOLUNTEER offers to help ISHA are welcome!

The forum function is available and all members are encouraged to sign in frequently and participate! In addition, there is a video archive where members-only are able to upload, view and comment upon videos. The process for video editing is currently being developed for eventual widespread use. Derek Ochiai continues to help ISHA with his efforts in our social media presence and Committee Members Marcelo Queiroz, Tom Sampson and Al Stubbs have worked hard to ensure your e-presence is in top form. Please contact our communications committee link on the site with any ideas or suggestions that you would like to see added. See you in Chile! John Christoforetti, Chair Communications Committee

ISHA Twitter

Derek Ochiai, MD

Why YOU should join Twitter (and help ISHA)

Social media, for better or worse, is here to stay. Facebook

now has over one billion active users, and Twitter has 313

million. Your patients are using social media, even if you’re

not. Your patients are talking about you and your practice on

social media, even if you are not engaging social media.

Fortunately, you did have some control over your social

media image, and one way is to join Twitter.

Full disclosure: I am a big Twitter fan. I use it personally, because I follow all major

news outlets, and I can get information much quicker than if I were to sit in front of

CNN for half an hour. Professionally, I use it to post information about hip

arthroscopy. If you write a blog about some aspect of hip arthroscopy, how will

people see it? Sure, they can probably find it through your practice website, but

unless they know to search for it, interested patients may not find it. Having a

presence on Twitter allows the public to find you and any relevant information you

have to offer. It is a way of countering the sometimes maddening misinformation

that is on the web. By posting it on Twitter, if someone likes what you write, they can

retweet it, amplifying your message, sending it to all their followers.

Twitter does not require ANY two way communication. You do not have to “friend”

anybody. If someone follows you, there is no “code of conduct” saying you have to

in return follow them. In this sense, it is more anonymous than Facebook or

LinkedIn.

ISHA has a Twitter site (@ISHASociety). Please think about joining Twitter and

following us! It really takes two minutes to join Twitter, and all you need is your email

address. Following us on Twitter allows ISHA to amplify our message of bringing

research driven Hip Arthroscopy and Hip Preservation information to the public.

Derek Ochiai, MD

Orthopaedic Srugeon, Nirschi Orthopaedic Centre, Arlington, VA, USA

ISHA Melbourne 2018

John O’Donnell

10 year Anniversary of

ISHA

"The 2018 Annual ISHA Scientific Meeting will be held in Melbourne, Australia from October 4-6. This will be the 10th Anniversary Meeting of ISHA, and we are planning some special events to mark this achievement. It will also be the first meeting of the newly changed ISHA which will officially include open hip preservation surgery into our

name, and open hip preservation surgeons into our great fellowship of friends. Melbourne is Australia’s second largest city, and has, on seven consecutive occasions, has been voted the World’s most liveable city. It is also the birthplace of hip arthroscopy in Australia and remains the hip arthroscopy centre of the country. It is a very safe city, with excellent public transport, making it very easy to visit the many attractions we have to offer. Melbourne is also easily reached by air, with many airlines having direct flights to Melbourne International Airport, and many others connecting via Sydney. The Conference will be held in the new, state of the art, Melbourne Convention and Exhibition Centre. There are 2 hotels, including a new Novotel attached to the Centre, and there are many accommodation options within easy walking distance. October is usually a beautiful time with warm Spring days, and the many parks and gardens in full bloom. As well, this is the time of the Australian Football Finals, and there will be an air of anticipation and excitement, with the Grand Final Parade, and many other events on around this time. Melbourne is also a great place to bring your family. There are many wonderful things to do and places to visit for people of all ages.

There are also outstanding attractions close to the city, such as the Healesville Wildlife Sanctuary, full of Australia’s unique animals, or the Great Ocean Road. And, of course, Australia is a big and very different country, with many fantastic places to visit. I hope you will be able to join us for a great meeting, and maybe also stay on for a while."

John O’Donnell

Orthopaedic Surgeon, Hip Arthroscopy Australia, Melbourne, Australia

ISHA Commentary

Professor Ian Harris

“The Warwick Agreement”

The Warwick Agreement on femoroacetabular impingement

syndrome (FAI syndrome) is an international consensus

statement that aims to clarify and standardise some

terminology, diagnostic criteria and treatments for FAI

syndrome.

FAI syndrome has become a common diagnosis and there is considerable variability

in the diagnosis (does it have to be symptomatic?), the significance (is it always ‘pre-

arthritic’?) and the treatment (if the problem is anatomical, how does non-operative

treatment work?) which makes such a document timely, particularly as treatments

and research for this condition are expanding. The questions asked in the statement

are relevant to current practice and are all questions that need answering, even if the

statement cannot answer all of them.

The statement draws experts from different fields and does refer to a literature

review, but the robustness of the systematic review cannot be determined as it is not

included. The results of such a review would be of some value to those interested in

this field.

Although there was some preparation, the consensus statement was largely

completed during a one-day meeting, rather than using more established methods

for gaining consensus among experts such as the Delphi method.

Fortunately, a high degree of consensus was reached. The first few consensus

statements relate to diagnostic definitions, criteria and clinical signs and are all

reasonable and an improvement on current terminology. The imaging statement

adds little, although arguably because there was little debate in this area. The

treatment statement is limited by the available evidence and therefore does little

more than list the currently available treatments and suggest that each be

considered. The aims of each treatment are listed, but this does not tell us the

comparative effectiveness, or net effectiveness of each treatment.

The prognostic statement is also limited by a lack of evidence, leading to a

somewhat contradictory conclusion that untreated FAI will ‘probably’ worsen over

time, but that the long term outlook is ‘unknown’.

The authors are careful to highlight the lack of high quality evidence supporting the

statements and provide a useful summary table of 6 RCTs of FAI treatment that are

currently recruiting. It is reassuring to see such broad involvement in generating this

high quality evidence.

ISHA Commentary

As it stands, the Warwick Agreement on FAI syndrome is an up to date summary of

the topic, prepared by experts in the field. It provides useful information on diagnostic

criteria and terminology and summarises the current treatment options. It also points

the way to when and where the future evidence on treatment effectiveness will be

generated.

Ian Harris

University of New South Wales, Western Sydney Clinical School, Liverpool Hospital,

Liverpool, Sydney, Australia

ISHA HOT TOPIC ARTICLES

Robert Buly MD

Angular deformities of the proximal femur

With the increasing understanding of the long-term consequences of acetabular dysplasia, femoroacetabular impingement and angular deformities of the proximal femur such as coxa valga and coxa vara, only a minority of cases of hip osteoarthritis are now classified as "idiopathic." However, one type of hip deformity that is still frequently overlooked are

rotational deformities of the femur, i.e. excessive anteversion or femoral retroversion. Rotational femoral deformities may coexist with acetabular dysplasia, various types of hip impingement, cerebral palsy, Perthes disease, and are not unusual after the fixation of femoral shaft fractures. Version abnormalities can occur with coxa valga or vara, or with a normal neck-shaft angle (125-140°). Femoral retroversion and excessive anteversion were seen in 13% and 16% respectively in patients with labral tears. CT scanning with axial slices through the femoral condyles as well as the hip is the best way to document femoral and acetabular version. It is important to note the sum of the combined version, called the McKibbin Index, because the abnormalities can be compounded. Normal anteversion is approximately 15° for both the femur and acetabulum, or a McKibbin index of 30°. Why should surgeons be concerned with femoral version abnormalities? Excessive anteversion can cause instability, damage of the articular cartilage and acetabular labrum and eventually osteoarthritis. Excessive femoral anteversion can cause a decrease in the length of the abductor lever arm by up to 28%. Excessive femoral anteversion has also been implicated as a source of posterior extra-articular impingement in hips with a valgus neck-shaft angle. The onset of pain in patients with dysplasia occurs earlier if there is coexistent excessive combined anteversion. Patients with symptomatic ischio-femoral impingement (IFI) are more likely to have excessive femoral anteversion compared to asymptomatic patients. Other problems associated with excessive femoral anteversion include increased hip and knee adduction moments and an intoeing gait. Increased femoral anteversion can cause patellofemoral maltracking, with resultant knee pain and arthritis. Femoral retroversion, on the other hand, causes damage to due to impingement between the femoral neck and acetabulum. This can cause damage to the labrum and articular cartilage, ultimately resulting in osteoarthritis of the hip. Femoral retroversion has been implicated as increasing the possibility of slipped capital femoral epiphysis due to higher shear forces. Impingement due to retroversion of the hip may increase the susceptibility to a traumatic posterior hip dislocation. Residual, untreated femoral retroversion may be a reason why hip preserving surgeries may fail, especially after the arthroscopic treatment of hip impingement. The goal then, should be to correct not only the malrotated femur, but any other associated abnormalities. If coexisting with coxa valga or coxa vara, the best approach might be the classic VRO, or varus (or valgus) rotational osteotomy. This


type of intertrochanteric osteotomy allows for the simultaneous correction of the neck-shaft angle as well as a rotation correction. However, what surgical approach can be used if the neck-shaft angle is normal? One can use the same lateral exposure used for a VRO, performing a pure rotational osteotomy in the subtrochanteric region with the application of a straight plate instead of a blade-plate. Alternatively, it is possible to perform the derotation osteotomy in a minimally-invasive fashion. Rather than a large incision that requires elevating the vastus lateralis off the proximal femur, the osteotomy site is not exposed. A small incision is performed proximal to the greater trochanter, just long enough to gain access to the medullary canal via the top of the trochanter. The osteotomy is performed in the supine position under regional, hypotensive anesthesia. The operated leg is draped free and traction is not employed. (Figure 1) An intramedullary Winquist hand saw (Biomet, Warsaw, Indiana, USA) is used. (Figure 2) The saw is available in 6 sizes: 12 to 17mm, that will transect bone diameters from 20 to 35mm. Obviously, the saw size is limited by the diameter of the femoral canal. The isthmus of the femur is over-reamed by 0.5 mm in accordance with the nail to be used. The subtrochanteric region is then reamed 0.5 mm larger than the diameter of the proposed intramedullary saw to be used. Rotational control is achieved by placing 1/8 inch smooth Steinmann pins into the femur proximal and distal to the osteotomy in the desired amount of rotational correction. The angular correction is controlled visually by using flat, triangular guides from a blade-plate instrument set (DePuy Synthes, Raynham, MA). Figure 1: Accessing the proximal femur


Figure 2: An intramedullary Winquist hand saw

The osteotomy is then performed in the sub-trochanteric region by inserting the hand saw which is rotated in a stepwise fashion with progressive protrusion of the blade from the cam. The location and progress of the osteotomy is controlled by fluoroscopy. The distal fragment is then rotated to align the two pins parallel, thus effecting the rotational correction. The goal is to achieve approximately 15° of femoral anteversion. Fixation can then achieved using an intramedullary nail that is locked proximal and distal to the osteotomy. Concomitant hip arthroscopy can be performed just prior to the osteotomy (same day) if the MRI scan reveals labral and/or articular cartilage lesions or the presence of a cam lesion of the femoral neck that would impinge if a retroverting derotation femoral osteotomy was to be performed for excessive anteversion. A concomitant peri-acetabular osteotomy can be performed at the same setting if there is coexisting, severe dysplasia that requires correction along with the femoral version. The peri-acetabular osteotomy was performed first with the same preparation and drape set up used for both procedures. A concomitant tibial/ fibular osteotomy can be performed if the patient has a compensatory, external tibial torsion coexisting with excessive femoral anteversion. This is done to prevent an exaggerated external foot progression angle that would result from derotating the excessively anteverted femur in patients with this rotational deformity. Weight bearing as tolerated can be permitted with crutches unless a concomitant peri-acetabular or tibial osteotomy is performed, in which case the weight bearing should be restricted to 20% for six weeks. Follow-up examinations with AP and lateral radiographs are performed at 6 weeks, three months, six months and at one year following surgery. Caveats:

1) MRI scans can be used to assess femoral version, but the prolonged acquisition time may lead to an erroneous measurement if the squirming


2) patient rotates the legs between imaging the hips and knees. In addition, we

find 3D-CT scans to be extremely useful to assess acetabular version, pincer and cam lesions.

3) The derotation osteotomy technique works best if the patient with excessive anteversion has an intoeing gait and conversely, an external rotation gait with retroverted patients. We have had to concomitantly internally rotate the tibia in 17% of our anteverted cases. It has not been necessary to perform any tibial osteotomies with our retroverted cases.

4) The Winquist saw will almost always complete the transverse osteotomy. It may not completely osteotomise the femur if the patient has very thick cortices and a narrow canal. In those cases, it has been necessary to make a small incision at the osteotomy site and complete the transection (always the lateral cortex, which is thicker) with a ¼” osteotome.

5) Healing of the osteotomy may take longer than an intertrochanteric VRO osteotomy, averaging 3-4 months due to the smaller surface area and cortical bone at the osteotomy site.

In summary, this technique allows for the correction of femoral version abnormalities in a minimally invasive fashion. Surgeons should routinely assess version, since if not measured or ignored, may result in continued hip pain and degeneration. Robert Buly MD Chief, Hip Preservation Service, Hospital for Special Surgery Associate Attending Orthopaedic Surgeon, Hospital for Special Surgery Associate Professor of Clinical Orthopaedic Surgery, Weill Cornell Medical College References Tonnis D, Heinecke A. Acetabular and femoral anteversion: relationship with osteoarthritis of the hip. J Bone Joint Surg Am. 1999 Dec;81(12):1747-70. Winquist RA. Closed intramedullary osteotomies of the femur. Clin Orthop. 1986 (212):155-64.


The Cost-Effectiveness of Hip Arthroscopy

Seper Ekhtiari MD and Olufemi R. Ayeni MD MSc FRCSC

*Please note: all cost and currency values have been

converted to Euros, based on conversion rates obtained at

time of writing. This has been performed to allow for

comparison between studies. In the interest of accuracy and

transparency, all original values and currencies are provided

in parentheses.

The quantity and quality of literature being published on the topics related to hip

arthroscopy and femoro-acetabular impingement (FAI) has been rising rapidly

throughout the first half of this decade[14]. This comes as part of a global increase in

the use of the hip arthroscopy over the past fifteen years[2, 8]. As well, hip

arthroscopy is increasingly being incorporated into residency and fellowship training

programs [5]. Thus far, the evidence for the clinical benefits of hip arthroscopy

appears promising: overall, hip arthroscopic procedures provide good outcomes with

low complications rates, and result in faster post-operative recovery and lower

morbidity when compared with open procedures[1, 3, 10, 15–17, 22].

Clinical benefit, however, is not the only measure of an acceptable healthcare

intervention, costs must be factored in. We work in a climate of rapidly growing

healthcare costs – according to The Organisation for Economic Co-operation and

Development (OECD), healthcare spending rose faster than economic growth in all

35 OECD countries between 1990 and 2012[19]. An ageing population with

increased medical demands and the rise of new medical technologies are important

drivers of the rising costs of providing healthcare[19]. Thus, with patient care always

remaining the primary goal, we must be thoughtful and deliberate about the

incorporation of new techniques and technologies in healthcare, ensuring that they

are both clinically beneficial and economically sensible.

A comprehensive review of healthcare economics is beyond the scope of this piece,

but many resources exist[6, 12, 23]. Briefly, a new healthcare intervention can be

compared to current practice on two basic parameters: cost and clinical benefit. This

analysis can be quantified as “additional cost per additional benefit” – in other words,

additional dollars spent per unit of benefit gained[11]. This is known as the

incremental cost effectiveness ratio (ICER). The denominator in this equation (i.e.,

“the benefit”) can be represented in myriad ways, such as a laboratory value (e.g.,

serum creatinine), life years gained (LYG), or, difference in quality-adjusted life years

(QALY). Though no formal cut-offs have been established, in general, interventions

with a cost lower than about €23,400 per QALY (original: £20,000) are considered to


be cost-effective[18]. For comparison, the cost of haemodialysis per QALY is about

€46,700 (original: USD $50,000)[7].

The available literature on the economics of hip arthroscopy is limited yet improving.

Clement et al. undertook a cost analysis for 58 patients undergoing hip arthroscopy

for FAI. In that study, the estimated cost of hip arthroscopy was €3,598 (original:

£3,083). The QALY gain was 0.159 at one year, 0.318 at two years, and 1.59 at ten

years. The ICER at one year was €26,388 at one year, €13,805 at two years, and

€3,654 at ten years (originals: £22,571, £11,808, and £3,125, respectively)[4].

Shearer et al. used a Markov model for typical hip arthroscopy patients to conduct a

cost-effectiveness analysis, and found an ICER of €20,300 (original: USD $21,700)

using a conservative estimate of symptom relief for three years. As well, these

investigators found that arthroscopy was cost-effective as long as it provided 13

months of improvement in quality of life[21]. In a systematic review that was

supplemented with a chart review of twenty patients, de SA et al. attempted a direct

comparison of hip arthroscopy with surgical hip dislocation (SHD) for treatment of

FAI. The authors reported 60% cost-savings when arthroscopy was used as

compared to SHD, with costs of €7,835 vs. €17,402, respectively (originals: CAD

$10,976 vs. CAD $24,379, respectively)[20]. Most of this difference was due to

decreased in-patient hospital stay cost associated with hip arthroscopy. Finally, in

an interesting analysis of the cost of delayed diagnosis, Kahlenberg et al. surveyed

78 symptomatic FAI patients with confirmed labral tears and found that patients saw

a mean of 4.0 healthcare providers, underwent 3.4 diagnostic tests, attempted 3.1

treatments prior to accurate diagnosis, and waited 32.0 months before receiving an

accurate diagnosis. The healthcare cost of this delay in diagnosis was estimated at

€2,296, compared to €645 for patients referred directly to a specialist who received a

timely diagnosis (original: USD $2,456.97 vs. USD $690.62). Importantly, this cost

difference did not include the potential long-term implications of progressive damage

to the hip joint over that time period[13].

Thus, while the literature is relatively limited by the number of studies to analyse, the

current evidence supports the cost-effectiveness of hip arthroscopy as a treatment

for FAI. As well, the timely recognition and diagnosis of related conditions, such as

labral tears, are an important source of cost-savings. There is a need for

prospective, long-term, well-controlled studies that further characterize and examine

the cost-effectiveness of hip arthroscopy. As well, the prospective inclusion of cost-

effectiveness as an outcome in future randomized-controlled trials will allow for a

more accurate and comprehensive understanding of the true costs of hip

arthroscopy as compared with other management strategies. The importance of

these analyses is already being recognized, as evidenced by the inclusion of cost-

effectiveness as an outcome measure in the published protocols of ongoing trials[9].

Finally, I encourage all hip preservation and arthroscopic surgeons to similarly


incorporate the measures of cost benefit and/or effectiveness to their ongoing clinical

studies.

Olufemi R. Ayeni MD MSc FRCSC

Associate Professor of Orthopaedic Surgery and Fellowship Director of the Sports

medicine and arthroscopy fellowship at McMaster University, Canada

1. Botser IB, Smith TW, Nasser R, Domb BG (2011) Open surgical dislocation versus

arthroscopy for femoroacetabular impingement: A comparison of clinical outcomes.

Arthroscopy 27:270–278. doi: 10.1016/j.arthro.2010.11.008

2. Bozic KJ, Chan V, Valone FH, Feeley BT, Vail TP (2013) Trends in hip arthroscopy

utilization in the United States. J Arthroplasty 28:140–143. doi:

10.1016/j.arth.2013.02.039

3. Clarke MT, Arora A, Villar RN (2003) Hip arthroscopy: complications in 1054 cases. Clin

Orthop Relat Res 84–88. doi: 10.1097/01.blo.0000043048.84315.af

4. Clement N, MacDonald D, Gaston P (2014) Hip arthroscopy for femoroacetabular

impingement: A health economic analysis. HIP Int 24:457–464.

5. Colvin AC (2012) Trends in Hip Arthroscopy. J Bone Jt Surg 94:e23 1. doi:

10.2106/JBJS.J.01886

6. Detsky AS, Naglie IG (1990) A clinician’s guide to cost-effectiveness analysis. Ann Intern

Med 113:147–154. doi: 10.7326/0003-4819-113-2-147

7. Dougherty CP, Howard T (2013) Cost-effectiveness in orthopedics: providing essential

information to both physicians and health care policy makers for appropriate allocation

of medical resources. Sports Med Arthrosc 21:166–8. doi:

10.1097/JSA.0b013e31829eb848

8. Erickson BJ, Cvetanovich GL, Frank RM, Bhatia S, Bush-Joseph CA, Nho SJ, Harris JD

(2015) International trends in arthroscopic hip preservation surgery-are we treating the

same patient? J hip Preserv Surg 2:28–41. doi: 10.1093/jhps/hnv013

9. FIRST Investigators (2015) A multi-centre randomized controlled trial comparing

arthroscopic osteochondroplasty and lavage with arthroscopic lavage alone on patient

important outcomes and quality of life in the treatment of young adult (18–50)

Femoroacetabular impingement. BMC Musculoskelet. Disord. 16:

10. Griffin DR, Villar RN (1999) Complications of arthroscopy of the hip. J Bone Joint Surg Br

81:604–606. doi: 10.3109/13645709609152703

11. Hill SR (2012) Cost-effectiveness analysis for clinicians. BCM Med 10:1–3. doi:

10.1186/1741-7015-10-10

12. Jena AB, Philipson TJ (2008) Cost-effectiveness analysis and innovation. J Health Econ

27:1224–1236. doi: 10.1016/j.jhealeco.2008.05.010

13. Kahlenberg CA, Han B, Patel RM, Deshmane PP, Terry MA (2014) Time and Cost of

Diagnosis for Symptomatic Femoroacetabular Impingement. Orthop J Sport Med 2:1–7.

doi: 10.1177/2325967114523916

14. Khan M, Oduwole KO, Razdan P, Phillips M, Ekhtiari S, Horner NS, Samuelsson K, Ayeni

OR (2016) Sources and quality of literature addressing femoroacetabular impingement: a

scoping review 2011-2015. Curr Rev Musculoskelet Med 9:396–401. doi:

10.1007/s12178-016-9364-5

15. Larson CM, Clohisy JC, Beaulé PE, Kelly BT, Giveans MR, Stone RM, Samuelson KM (2016)

Intraoperative and Early Postoperative Complications After Hip Arthroscopic Surgery: A

Prospective Multicenter Trial Utilizing a Validated Grading Scheme. Am. J. Sports Med.

16. Larson CM, Giveans MR (2009) Arthroscopic debridement versus refixation of the

acetabular labrum associated with femoroacetabular impingement. Arthroscopy 25:369–

76. doi: 10.1016/j.arthro.2008.12.014

17. McGinn T, Wyer PC, Newman TB, Keitz S, Leipzig R, For GG (2004) Tips for learners of

evidence-based medicine: 3. Measures of observer variability (kappa statistic). CMAJ

171:1369–73. doi: 10.1503/cmaj.1031981

18. National Institute for Health and Clinical Excellence (2008) Social Value Judgements

Principles for the development of NICE guidance. Natl Inst Heal Care Excell 1–36. doi:

10.1136/bmj.324.7351.1413/a

19. OECD (2015) Fiscal Sustainability of Health Systems: Bridging Health and Finance

Perspectives. doi: http://dx.doi.org/10.1787/9789264233386-en

20. de Sa D, Horner NS, MacDonald A, Simunovic N, Slobogean G, Philippon MJ, Belzile EL,

Karlsson J, Ayeni OR (2015) Evaluating healthcare resource utilization and outcomes for

surgical hip dislocation and hip arthroscopy for femoroacetabular impingement. Knee

Surg Sports Traumatol Arthrosc. doi: 10.1007/s00167-015-3722-5

21. Shearer DW, Kramer J, Bozic KJ, Feeley BT (2012) Is hip arthroscopy cost-effective for

femoroacetabular impingement? In: Clin. Orthop. Relat. Res. pp 1079–1089

22. Sim Y, Horner N, de Sa D, Simunovic N, Karlsson J, Ayeni OR (2015) Reporting of non-hip

score outcomes following femoroacetabular impingement surgery: a systematic review. J

Hip Preserv Surg 2:224–41.

23. Tan-Torres Edejer T, Baltussen R, Adam T, Hutubessy R, Acharya A, Evans DB, Murray CJL

(2003) WHO guide to cost-effectiveness analysis.


Does Hip Arthroscopy Prevent a Total Hip

Replacement?

Ajay Malviya & Vikas Khanduja

The association between femoro-acetabular impingement (FAI) and osteoarthritis was the subject of a recent systematic review[1]. Although a link has been established between FAI, in particular Cam type lesion, and osteoarthritis the role of hip arthroscopy in preserving the native joint and delaying the need for hip replacement (THR) is

a matter of constant debate. It is clear that despite the exponential increase in the number of hip arthroscopies performed[2], explicit evidence supporting long-term success is limited. This is compounded by the evolving scope of the procedure with wide variation in the intervention offered depending possibly on the learning curve of the surgeon and the facilities available. It is also well known that the results are predominantly dictated by the degree of degeneration noted at the time of surgery, and time and again the conclusions of various studies have resonated the same conclusion.

Shearer et al[3] constructed a Markov model including possible health states for 36-year-old patients with FAI, using decision analysis software and compared two strategies: observation and hip arthroscopy; followed by THR with disease progression. They estimated the ratio of the incremental cost to the incremental benefit (reflected by health related quality of life) of both strategies and identified studies reporting Harris hip scores and complications after arthroscopy to estimate health state preferences and their probabilities. A sensitivity analysis was performed to determine the influence of uncertainty on the incremental cost-effectiveness ration (ICER) with particular emphasis on the magnitude and duration of benefit. Among patients with FAI but no radiographic evidence of arthritis, the estimated ICER of hip arthroscopy was $21,700/QALY (quality-adjusted life-year) while the ICER for patients with preoperative arthritis was $79,500/QALY. Alteration of the natural history of arthritis by hip arthroscopy improved the ICER to $19,200/QALY and resulted in cost savings if THR was not performed until at least 16 years after

arthroscopy. Clearly, the primary benefit of hip arthroscopy for FAI in terms of cost effectiveness would be when there is delay in the need for THR beyond sixteen years.

Moreover, whilst consenting patients, the paramount question to be answered is the rate of success of the procedure in terms of the long-term survival of the native hip. This would clearly depend upon several factors like age, gender, and degree of degeneration on radiographs, degree of chondropathy noted at the time of the surgery and the underlying cause of the labral/chondral dysfunction. In this article we’ll try to address these issues looking at the different forms of evidence available.


Systematic reviews

Nwachukwu et al[4] in a systematic review published recently explored the medium to long-term outcome after impingement surgery. The aim was to specifically look at total hip replacement (THR) as the endpoint at a minimum mean follow-up of three years. The authors could find only 16 suitable studies; nine, which looked at open surgical hip dislocations and seven looking at hip arthroscopies. Open studies included 600 hips at a mean follow-up of 57.6 months (4.8 years; range, 6-144 months); arthroscopic studies included 1484 hips at a mean follow-up of 50.8 months (4.2 years; range, 12-97 months). With THR as an endpoint, there was an overall survival rate of 93% for open and 90.5% for arthroscopic procedures (p =0.06). Following arthroscopic treatment for FAI, 141 hips (9.5%) were converted to THR during a maximum follow-up period of 8.1 years (range, 12-97 months). Advanced age, female gender and pre-existing chondral injury were the main risk factors identified for progression to THR following both treatments.

Griffin et al[5] in their systematic review on the results of hip arthroscopy in patients older than 40 years reported an overall rate of conversion to THR of 18.5% (65/351 patients), at a mean of 17.5 months following arthroscopy.

Single surgeon long-term series

McCarthy et al[6] retrospectively reviewed 324 patients (340 hips) who underwent arthroscopy for pain and/or mechanical symptoms of catching. Of these, 106 patients

(111 hips or 33%) had a minimum follow-up of 10 years (mean, 13 years; range, 10-20 years). The average age was 39 years (+/- 13) with 47 men and 59 women. Overall survivorship among the 111 hips was 63% at 10 years, with age at arthroscopy and Outerbridge grades as independent predictors of outcome. Gender and the presence of a labral tear did not influence long-term survival. Thus patients aged less than 40 years with Outerbridge grade 0 to II had a 10% risk of conversion to THR over 10 years while patients older than 40 years with higher Outerbridge grade (III-IV) had a risk of 99% to be converted to THR. Regression analysis revealed that the odds of progressing to a THR would be 3.6 times higher in patients over the age of forty, 20 times higher with acetabular lesions of grade III-IV (Outerbridge) and 58 times higher with femoral lesions of grade III-IV (Outerbridge).

In another single-surgeon, prospective analyses[7] of the role of joint preservation after hip arthroscopy, the authors reported on a series of 42 consecutive patients at a minimum follow-up of seven years. At the final follow-up, the joint preservation rate was 83.33% (CI-95% 68,64%-93,03%). Probability of evolving to a THR in patients with pre-operative Tönnis grades of 0 and I was of 0% (CI 95%: 0-12.77) whilst the probability in patients with a pre-operative Tönnis grades of II and III was 46.67% (CI 95%21.27%-73,41%). A statistically significant difference was present between both groups (p= 0.002). Patients older than 45 years at the time of hip arthroscopy were at significant risk of evolving to a THR (p=0.0012).

Results in osteoarthritis

Haviv et al[8] determined that 16% of the patients undergoing hip arthroscopy for


Tönnis Grade 1-3 osteoarthritis would require a THR over a period of seven years. Similarly Larson et al[9] noted a 12% failure rate in the FAI group without OA as compared with 33% for the group with FAI and mild to moderate OA (<50% joint space narrowing or > 2mm of joint space) and 82% failure rate in the group with advanced OA (>50% joint space narrowing or < 2mm of joint space). Similar results were observed in the study by Philippon et al[10] looking at 153 patients over the age of 50 years with twenty per cent progressing to a THR. At three years, data were available for 64 patients with a Kaplan-Meier survival of 90% in patients with more than 2 mm joint space and 57% in those with a joint space of 2 mm or less (p=0.01).

A counter argument would be that hip arthroscopy improved outcome scores in 56% of patients with severe OA of the hip (Tönnis grade 2 and 3) for at least two years following surgery, although the authors report that 44% of the patients required a total hip replacement at mean of 18 months (6 to 48) after hip arthroscopy[11].

Piuzzi et al[12] also looked at the literature for hip arthroscopy in the background of osteoarthritis and found inconclusive evidence to make categorical indications for hip arthroscopy in the treatment of OA. Although there was some improvement in clinical outcome post-operatively especially related to pain and function in the short-term. Increasingly worse outcomes were seen as the severity of OA progressed. The overall conversion rate to a THR ranged from 9.5% to 50% with the mean time between arthroscopy and THR being 13.5 months.

Population based studies

Whilst there is benefit in knowing the results of surgery by individual surgeons there is an inherent risk of publication bias, with most studies being performed, reported, cited and published by high volume surgeons. Population based studies help us understand and explore the results in “non-expert” hands.

Schairer et al[13] used the State Ambulatory Surgery Databases and State Inpatient Databases for California and Florida from 2005 through 2012 and tracked hip arthroscopy patients for subsequent primary THR within 2 years. They identified 7,351 patients who underwent hip arthroscopy with 2 years follow-up. Overall, 11.7% of patients underwent conversion to a THR within 2 years. The conversion rate was lowest in patients aged younger than 40 years (3.0%) and highest in the 60- to 69-year-old group (35.0%) (p<0.001). An increased risk of conversion to a THR was found in older patients and in patients with osteoarthritis or obesity at the time of hip arthroscopy. Patients treated at high-volume hip arthroscopy centres had a lower rate of conversion to a THR than those treated at low-volume centres (15.1% v 9.7%, p <0.001).

Malviya et al[14] reviewed the complications and survival analyses of 6,395 hip arthroscopies performed in the National Health Service in England between April 2005 and Jan 2013. THR was performed in 680 patients (10.6%) at a mean of 1.4

years after the index operation. Kaplan-Meier survival analysis showed an 8-year survival rate of 82.6% (95% confidence interval [CI], 80.9% to 84.2%), whereas Cox proportional hazard analysis adjusting for age, gender, and Charlson comorbidity score showed an 8-year survival rate of 86%. Female patients had a 1.68 times


(95% CI, 1.41 to 2.01) higher risk of conversion to a THR than male patients, and patients aged 50 years or older had a 4.65 (95% CI, 3.93 to 5.49) times higher risk of requiring hip replacement than patients younger than 50 years.

Conclusion

Evaluating the evidence available currently, it is clear that whilst hip arthroscopy is a good pain relieving procedure that results in improvement in function, its long-term role in delaying the need for a THR has not yet been established. Evidence also suggests that greater age and advanced chondropathy are poor prognostic factors and possibly gender, obesity and low surgeon volume also carry negative prognostic implications. Finally, if the sixteen-year benchmark is to be set as the threshold for cost-effectiveness, as established by Shearer et al[3], more evidence is certainly required.

Ajay Malviya PhD, FRCS T&O, MSc, MRCSEd, MS T&O

Honorary Senior Lecturer Newcastle University

Consultant Orthopaedic Surgeon,Northumbria Healthcare NHS Foundation Trust,Northumbria, UK.

Vikas Khanduja, MA (Cantab), MRCS (G), MSc (Orth Eng), FRCS, FRCS (T & O)

Consultant Orthopaedic Surgeon & Elective Clinical Trials Lead

Addenbrooke’s – Cambridge University Hospital,Cambridge, UK

References

1. Kowalczuk, M., et al., Does Femoroacetabular Impingement Contribute to the Development

of Hip Osteoarthritis? A Systematic Review. Sports medicine and arthroscopy review,

2015. 23(4): p. 174-9.

2. Palmer, A.J., et al., Past and projected temporal trends in arthroscopic hip surgery in

England between 2002 and 2013. BMJ open sport & exercise medicine, 2016. 2(1): p.

e000082.

3. Shearer, D.W., et al., Is hip arthroscopy cost-effective for femoroacetabular impingement?

Clinical orthopaedics and related research, 2012. 470(4): p. 1079-89.

4. Nwachukwu, B.U., et al., Arthroscopic Versus Open Treatment of Femoroacetabular

Impingement: A Systematic Review of Medium- to Long-Term Outcomes. The American

journal of sports medicine, 2016. 44(4): p. 1062-8.

5. Griffin, D.W., et al., Outcomes of Hip Arthroscopy in the Older Adult: A Systematic Review of

the Literature. The American journal of sports medicine, 2016.

6. McCarthy, J.C., et al., What factors influence long-term survivorship after hip arthroscopy?

Clinical orthopaedics and related research, 2011. 469(2): p. 362-71.

7. Comba, F., et al., Joint preservation after hip arthroscopy in patients with FAI. Prospective

analysis with a minimum follow-up of seven years. Muscles, ligaments and tendons

journal, 2016. 6(3): p. 317-323.

8. Haviv, B. and J. O'Donnell, The incidence of total hip arthroplasty after hip arthroscopy in

osteoarthritic patients. Sports medicine, arthroscopy, rehabilitation, therapy &

technology : SMARTT, 2010. 2: p. 18.

9. Larson, C.M., M.R. Giveans, and M. Taylor, Does arthroscopic FAI correction improve

function with radiographic arthritis? Clinical orthopaedics and related research, 2011.

469(6): p. 1667-76.

10. Philippon, M.J., E.S.B.G. Schroder, and K.K. Briggs, Hip arthroscopy for femoroacetabular

impingement in patients aged 50 years or older. Arthroscopy : the journal of arthroscopic

& related surgery : official publication of the Arthroscopy Association of North America

and the International Arthroscopy Association, 2012. 28(1): p. 59-65.

11. Daivajna, S., A. Bajwa, and R. Villar, Outcome of arthroscopy in patients with advanced

osteoarthritis of the hip. PloS one, 2015. 10(1): p. e0113970.

12. Piuzzi, N.S., et al., Hip arthroscopy in osteoarthritis: a systematic review of the literature.

Hip international : the journal of clinical and experimental research on hip pathology

and therapy, 2016. 26(1): p. 8-14.

13. Schairer, W.W., et al., Use of Hip Arthroscopy and Risk of Conversion to Total Hip

Arthroplasty: A Population-Based Analysis. Arthroscopy : the journal of arthroscopic &

related surgery : official publication of the Arthroscopy Association of North America

and the International Arthroscopy Association, 2016. 32(4): p. 587-93.

14. Malviya, A., et al., Complications and survival analyses of hip arthroscopies performed in

the national health service in England: a review of 6,395 cases. Arthroscopy : the journal

of arthroscopic & related surgery : official publication of the Arthroscopy Association of

North America and the International Arthroscopy Association, 2015. 31(5): p. 836-42.

ISHA Hip Arthroscopy in Asia

Korean Society for Hip Arthroscopy and Joint

Preservation

Pilsung Kim MD., Deuksoo Hwang MD

Since the establishment of the 'Hip Arthroscopy meeting'

(hereinafter referred to as the 'Hip Arthroscopy Study

group') at the Chungnam National University

Hospital(CNUH) in 2008, a team of professors at domestic

university hospitals has been working on the development of the Korean hip

arthroscopy. Regular meetings have been held twice a year since 2008 for the

purpose of overcoming the difficulty and the learning curve of the early arthroscopy,

exchanging information between the two, and establishing the arthroscopic

technique and the correct indications. The annual spring forum held a roundtable

meeting with the executives of the research institute and visited the training clinic,

and a total of eight forum were held until 2015. The CNUH Hip Arthroscopy

Symposium was held at the Chungnam National University Hospital in Daejeon to

play a role as a forum for academic and information exchange. The initial officers

and members of the

Korea hip society were

centred on the staff of the

university hospital, and

'Hip arthroscopy cadaver

workshop' was held in

2008 for the purpose of

education of hip

arthroscopy. Korean

specialists who are

interested in hip

arthroscopy have joined the Hip Arthroscopy meeting and now more than above 100

members are active. The worldwide trend in the conservative treatment of hip joint

disease is not only arthroscopic treatment but also the development of minimally

invasive operation including hip osteotomy, paediatric hip joint disease, and

arthroplasty. Therefore, The 'Korea hip arthroscopy meeting' was also renamed

'Korea hip arthroscopy and joint preservation research society'. In the '7th CNUH Hip

Arthroscopy and Preservation Symposium' in 2013, there was an exchange of

opinions on 'rehabilitation after hip surgery', 'joint cartilage preservation surgery' and

'arthroscopic treatment of joint diseases'. and updated hip arthroscopic cases of

members. In 1990s, hip arthroscopy was spreading in Korea. Deuk-Soo Hwang(DS

Hwang), a professor of Chungnam national university(CNU) has held hip

arthroscopic symposium and many doctors visited this symposium. In 2002, the 1st


CNUH hip arthroscopy symposium was opened and Dr. James Glick visited and

performed live surgery for Korean doctors. From that year, Thomas Sampson,

Thomas Byrd, Young-Jo Kim, Manfred Lais and John O’Donnell joined and

announced the application of the supine position and modern trend of hip

arthroscopy.

The 'Korea hip arthroscopy society' was initiated much faster than the Asian

countries such as China, Japan, Taiwan and Hong Kong, and is the center of Asia.

In this context, 'Asia hip arthroscopy society' was established as a member country

of Korea, Japan, China, Taiwan and Hong Kong in 2013, and 'the 1st Asian hip

arthroscopy & joint preservation symposium’ was held in Daejeon, Korea and Asinan

hip arthroscopy symposium has been held in Asian country annually. In 2014, Asian

regional hip arthroscopic interest group member including 3 Korean, 3 Japanese, 2

Tainwanee, 2 Hong-Kong and a China were gathered in Kitakyusu, Japan and made

various plan for development of

Asian hip arthroscopy.

Also, DS Hwang have made a lot

of effort for education of beginner

of hip arthroscopy. In 2008, he

opened ‘CNUH hip arthroscopy

cadaver workshop’ for Korean

doctors. From 2008 to 2012,

many Korean hip arthroscopist

had an experience and learned

procedures of hip arthroscopy.

This course was foundation of Korea hip arthroscopy society. At 2013, ‘CNUH hip

arthroscopy cadaver workshop was changed to ‘Asian hip arthroscopy cadaver

meeting’. At 2016, ‘The 3rd Asian hip arthroscopy cadaver meeting was held at

Bangkok, Thailand. Many Asian doctors including Korea, Japan, China, Taiwan,


Hong-Kona, India and Malaysia participated in this workshop. We will hold ‘The 4th

Asia hip arthroscopy cadaver workshop’ at Singapore, Feb. 24~25th, 2017 and ‘The

6th Asia hip arthroscopy & joint preservation symposium’ at China. Through this, the

Asia group is formed is actively engaged in the purpose of attracting a symposium of

the International Society of Hip Arthroscopy to Korea. Also, annual ‘Asia hip

arthroscopy symposium’ is going to hold in turn.

Many Korean doctors have a lot of interest ‘ISHA’ and have joined ‘ISHA annual

meeting’ since 2009. From 1st symposium, New York, 2009 to 8th symposium, San

Francisco, 2016, a lot of Korean doctors registered and have attended this

symposium annually. Additionally, Korea have above 15 ISHA ordinary members

and have close contact with ISHA. We hope that our Asia hip arthroscopy interesting

group will be transformed to ISHA Asia regional chapter and want to hold the ISHA

ASM in Asia as soon as possible in a future.

Dr Pilsung Kim MD, Bumin Hospital Seoul, Korea

Professor Deuksoo Hwang MD, Chungnam National University Hospital, Korea

ISHA Case Report

Dr JN Cakic (Chuck) MD , PhD , FCS(SA)Orth ,

MMed(Orth)WITS

HIP ARTHROSCOPY THROUGH THE DECADE - Case of Diaphysial aclasia

There is no doubt that in the last few decades we have witnessed an explosion in the field of hip preservation, especially within the technique of hip arthroscopy. Todays understanding of femoro-

acetabular impingement (FAI) and subsequent onset of labral pathology is becoming a common finding, but may not be the only indication for performing surgery. FAI is classically described as either Cam-type or Pincer-type, and been implicated as a causative factor for the development of hip arthritis (1). As the notion of hip impingement has evolved, so too has the concept of what may create the impingement. This understanding has expanded to incorporate extra-articular causes of FAI, namely, anterior inferior iliac spine/sub-spine impingement, trochanteric-pelvic impingement and ischio-femoral impingement (2). As with all specialize hip practices, one may often encounter patients with unusual presentations and / or diagnoses. One personal case come to mind which not only highlights the concept of FAI and but the implications of such a condition. This case presentation stretches over 13 years of conservative and surgical management and in my opinion highlights some of the development of the hip arthroscopy. In 2004, a teacher and personal mentor (hip arthroplasty surgeon) referred a patient with unexplained hip pain; his aim was to probe for a less invasive treatment solution than arthroplasty. I present to you, Mr GN, a 28-year-old geologist with a significant left hip pain. The supplied diagnosis included hereditary multiple exostosis (diaphysial aclasia) (3). This heritable disorder affects the endochondral skeleton during the period of growth and is characterized by thickening and deformity of the growing bone with the formation of numerous exostoses. In this case, both hips were involved.

Mr GN’s clinical history revealed the familial nature of this condition as it was present in his mother and extended to his sister. Multiple previous surgeries related to removal of exostoses in the region of the left knee as well as the right clavicle had already been undertaken. At the time of the initial consultation his complaint of

pain was isolated to the left hip, which had progressed over the past six months and reported to significantly interfere with his daily function. As a

ISHA Case Report

geologist, Mr GN, is required to perform labour intensive field work. He describes his function as 8/10 and his visual analogue pain scale was 2/10 which elevated to 8/10 with increased activity levels. Visual inspection was typical for the condition and despite his short stature he did not have significant skeletal deformities and asymmetries as commonly seen in diaphysial aclasia patients. When probing the onset of pain, Mr GN described positional pain that “catches” rather than being a continuous pain related to distance. The clinical examination revealed a relatively normal range of motion, however the left hip exhibited a positive stress tests related to intra-articular pathology, possibly labral in nature. MRI arthrogram confirmed the presence of a degenerative torn labrum and well preserved joint space. It was decided to to perform an arthroscopy of that hip. In 2004, my knowledge and experience of FAI treatment was only theoretical, hence management was limited to the central compartment by treating the labrum pathology via a partial debridement.(4). At the one-year follow-up mark with Mr GN, he now complained of hip impingement symptoms, specific to movement. A CT-scan identified a significant antero-medial exostosis of the femoral neck. With the new understanding of hip impingement presented by Prof. Ganz (1), I was better equipped to interpret how this exostosis could interfere with his function. A revision left hip arthroscopy was performed in June 2005, where the peripheral compartment was investigated and the large exostosis was decompressed successfully. Six months following the procedure, Mr GN was discharged with a normal function. Unfortunately, I have no intraoperative pictures to share with you. Fast forward five year (2010), Mr GN returned experiencing a similar presentation in his right hip. At that stage, he claimed that his left hip was functioning normally with no problems. Investigation into the right hip revealed the presentation of the FAI with secondary labral pathology. A hip arthroscopy was performed; intra-operative findings of the central compartment showed a well preserved chondral surface with calcified labrum, essentially presenting as a pincer. The peripheral compartment revealed a large exostosis, as expected with his condition. It is important to state that in 2010 the management of labral pathology was primarily performed via labral repair techniques; however, in the case of Mr GN, the calcified labrum was irreparable. Debridement, using an “over and above” technique, was performed, essentially a pincer decompression was performed.

ISHA Case Report

Following the 2010 surgery, Mr GN returned to his normal life reporting no complaints. But, as the old adage states: “Don’t count your chicken before they hatch”: Mr GN returned in 2016 complaining of a catching pain in the right hip with certain movements. The clinical examination pointed to the possibility of inadequate CAM resection, or capsular adhesion.

One only needs to read the literature to understand that a plethora of knowledge and technology relating to hip arthroscopy and treatment of many of the many related conditions has exploded and evidently resulted in new techniques being developed, notwithstanding the new and exciting diagnostic tools that are now available. In the case of Mr GN, a CT-based dynamic collision study was performed. This identified the presence of impingement, despite a previous decompression having been performed in 2010. It was presented as sub-spinal type of impingement. With this in mind a revision arthroscopy of the right hip was planned.

ISHA Case Report

Intra-operative findings of the central compartment were astounding. The labrum was remarkable repaired (remember that it was debrided in 2010). Some capsular adhesions presented were viably present, otherwise, the hip was in good condition. The peripheral compartment had a deformed CAM presentation, which obviously was not adequately removed in 2010. Based on CT-based collision study, an additional decompression was performed and followed by a dynamic movement testing to confirm that no further impingement was present.

The most recent follow up with Mr GN (eight months) revealed normal functioning, modified Harris hip score of 100, no presence of pain and his patient satisfaction of 10/10. It is rare to follow the development of an individual for 12 years especially when the interventions have almost paralleled the development and evolution of hip arthroscopy as a means of hip preservation. In summary, this case highlights my development as a hip arthroscopy surgeon in South Africa and a helps improve the understanding of a rare hereditary condition that has resulted in FAI. In the case of Mr GN, he is now functional and returned to a happy life. "Wherever the art of Medicine is loved, there is also a love of Humanity. ”     ― Hippocrates

References: 1. Ganz R, Parvizi J, Beck M, et al. Femoroacetabular impingement: a cause for

osteoarthritis of the hip. Clin Orthop Relat Res. 2003;417:112–120.

2. Larson CM, Kelly BT, Stone RM. Making a case for anterior inferior iliac

spine/subspine hip impingement: three representative case reports and proposed

concepts. Arthroscopy. 2011;27:1732–1737. 

3. Solomon L. Hereditary Multiple Exostosis. American Journal of Human

Genetics, 1964;3,VOL.16:351-363.

4. Kelly T.K., Williams R, Philippon M.Hip Arthroscopy: Current Indications, Treatment Options, and Management Issues.AJMS.2003;31.

ISHA Annual Scientific Meeting Update

Al Stubbs

Programme Chair, 2016 ISHA Annual Scientific Meeting

Dear Friends and Colleagues,

A tremendous thank you to all of you who supported and

travelled last September to San Francisco, California for the 8th

Annual Scientific Meeting of ISHA. The meeting was a genuine

representation of what makes ISHA special as an international

society of educators, researchers, and friends. True to our mission, we delivered on

representing our past achievements and the future innovations that will carry our

field of hip restoration into the next decade.

The 2016 ASM was a year of innovations to our meeting structure as well as a forum

for the latest science. Unique to the San Francisco ASM was our pre-meeting

Instructional Clinical Tutorials “ICTs” that paired instructor ISHA members with

surgeons eager to learn established and new techniques on dedicated cadaveric

models. These one-on-one opportunities were well received and provided a great

beginning to the first day. The ASM also was the introduction of “Presidential

Debates” between senior ISHA members to reflect on past science and present their

opinion on future trends.

The 2016 scientific program comprised over 60 research podium presentations, over

150 research poster presentations, and a concurrent physiotherapy program. There

were 18 Instructional Course lectures covering topics from cellular therapy to hip

conditions in athletes. True to prior meetings, the program represented eight trainee

presentations with the 2016 ISHA Basic Science Trainee Award to Dr. Juan Gomez-

Hoyos and colleagues and the 2016 Richard N. Villar Excellence in Clinical

Research Trainee Award to Dr. Shruti Raut and colleagues.

A special thank you to our Scientific Program Guest Speaker, Dr. Michael Longaker,

and our Presidential Guest Speaker, Dr. Jaap Suermondt – both were spectacular.

Dr. Longaker’s presentation the Skeletal Stem Cell was a fascinating perspective at

the role regenerative medicine will play in our field. Dr. Suermondt’s presentation on

What’s Next in Silicon Valley gave us an inside look at the subject of supercomputing

and where we are headed culturally and scientifically.

During the 2016 ASM, the leadership of ISHA made transitions as well as new

additions. Richard Field succeeded Marc Safran as ISHA President. Marc Philippon

was elected 2nd Vice-President following 1st Vice-President Chuck Cakic. Andreas

Fontana and Parminder Singh were added as General Board members.

ISHA Annual Scientific Meeting Update

A summary of the 2016 meeting would not be complete without recognizing two new

ISHA awards, the James M. Glick Award for Lifetime Achievement in Hip

Preservation which was awarded to its namesake, Dr. Glick, and the Joseph C.

McCarthy Award for Excellence in Hip Restoration Research which was awarded to

Dr. Marc Philippon. As an original pioneer in hip arthroscopy, Dr. Glick was also the

recipient of the 2016 Richard N. Villar Society Award.

In summary, I would like to thank the participants, faculty, special guests, industry

partners, and MCJ Consulting who made the 2016 ISHA ASM in San Francisco a

successful and memorable event. We are indebted to all of you who diligently and

cheerfully contributed your time, expertise, and enthusiasm!

Al Stubbs

Programme Chair, 2016 ISHA Annual Scientific Meeting

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