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Martin SD, Abraham PF, Varady NH, et al. Hip Arthroscopy Versus Physical Therapy for the Treatment of Symptomatic Acetabular Labral Tears in Patients Older Than 40 Years: A Randomized Controlled Trial. Am J Sports Med. 2021 Apr;49(5):1199-1208. doi: 10.1177/0363546521990789. Epub 2021 Mar 3. (Original study)
Abstract

BACKGROUND: Previous observational studies have suggested poor results of arthroscopic surgery for the treatment of acetabular labral tears in patients older than 40 years.

PURPOSE: To compare hip arthroscopy versus nonoperative management for symptomatic labral tears in patients older than 40 years who have limited radiographic osteoarthritis.

STUDY DESIGN: Randomized controlled trial; Level of evidence, 1.

METHODS: In this single-surgeon, parallel randomized controlled trial, patients older than 40 years who had symptomatic, MRI-confirmed labral tears and limited radiographic osteoarthritis (Tönnis grades 0-2) were randomized 1:1 to arthroscopic surgery with postoperative physical therapy (SPT) or physical therapy alone (PTA) using an electronic randomization program. PTA patients who achieved unsatisfactory improvement were permitted to cross over to SPT after completing =14 weeks of physical therapy. The primary outcomes were International Hip Outcome Tool (iHOT-33) and modified Harris Hip Score (mHHS) at 12 months after randomization, and secondary outcomes included other patient-reported outcome measures and the visual analog scale. Outcomes were assessed at baseline and at 3, 6, and 12 months after randomization. Primary analysis was performed on an intention-to-treat basis using linear mixed-effect models. Sensitivity analyses included modified as-treated analysis and treatment-failure analysis. Due to infeasibility, patients and health care providers were both unblinded.

RESULTS: The study enrolled 90 patients (46 [51.1%] SPT; 44 [48.9%] PTA); of these, 81 patients (42 [51.9%] SPT; 39 (48.1%) PTA) completed 12-month follow-up. A total of 28 of the 44 PTA patients crossed over to SPT within the study period (63.6% crossover). Intention-to-treat analysis revealed significantly greater iHOT-33 scores (+12.11; P = .007) and mHHS scores (+6.99 points; P = .04) in the SPT group than the PTA group at 12 months. Modified as-treated analysis revealed that these differences exceeded the minimal clinically important difference of 10.0 points (SPT-PTA iHOT-33, +11.95) and 8.0 points (SPT-PTA mHHS, +9.76), respectively.

CONCLUSION: In patients older than 40 years with limited osteoarthritis, arthroscopic acetabular labral repair with postoperative physical therapy led to better outcomes than physical therapy alone. Thus, age over 40 years should not be considered a contraindication to arthroscopic acetabular labral repair.

REGISTRATION: NCT03909178 (ClinicalTrials.gov identifier).

Ratings
Discipline Area Score
Physician 6 / 7
Comments from MORE raters

Physician rater

This is a single surgeon RCT (not generalizable), just concluding that 40 yr is not an age limit. It is not really contributing to the evidence on the technique.

Physician rater

This RCT provides new information as it looks at the effect of arthroscopic surgery + physical therapy for hip labral tears (compared to physical therapy alone) specifically in older (over 40) patients, and is supported by previous studies in younger patients.

Physician rater

The paper claims better results with arthroscopy group. However, it contradicts other papers dealing with the same issue. The problem with such papers is the variability in the methods of assessment, extent of labral tear, level of symptoms and patient needs, and bias of the researcher interpretation of results due to the interest of researchers, physical therapy groups vs orthopaedic surgeons.
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