Arthroscopic Labral Repair Versus Physical Therapy for Tears of the Acetabular Labrum

Study Overview
=================
Brief Summary
-----------------
Tears of the acetabular labrum appear to be common with the prevalence of asymptomatic tears in the general population approaching 66% and 70% based on cadaveric dissection and magnetic resonance imaging, respectively. Despite this prevalence, there is no currently accepted justification for performing labral repair in an asymptomatic patient despite the many postulated biomechanical benefits that an intact labrum imparts to the hip joint. Representing a smaller proportion of all tears, symptomatic tears of the acetabular labrum present a therapeutic challenge. Current treatment modalities range from conservative measures to open surgical intervention. Conservative measures have typically included: activity modification, the use of non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy (PT), core strengthening and improvement of sensory motor control. In the past two decades, technological advances in the form of surgical instrumentation and traction devices have facilitated less invasive arthroscopic techniques to diagnose and treat hip problems and as such is now the preferred treatment modality for many orthopedic surgeons treating patients with hip pathology. Determining which patients, using age and arthritic burden as predictors, can benefit from labral repair is paramount for several reasons. Showing arthroscopic repair is of little or no benefit to a specific cohort can reduce the number of unnecessary surgeries performed, increase the use of conservative therapy (if validated) and reduce the interval between diagnosis and total hip replacement.

Detailed Description
-----------------
There has been only one prospective study documenting the outcomes of patients treated with physical therapy for intra-articular conditions of the hip. These conditions included mild FAI and mild developmental dysplasia of the hip. Here, physical therapy was given as a first line treatment. Those who did not make satisfactory improvements in pain or wished to have surgery were then scheduled for surgery to repair the defects. Patients saw improvement in validated outcome measures at one year. Although there have been studies looking at age secondarily in patients with labral tears, there is no prospective evidence to endorse or refute a recommendation of hip arthroscopy for patients of any age being treated for a tear of the acetabular labrum. Most recently, the authors involved in this study performed a retrospective investigation (unpublished data) to capture patients with clinically and radiographically confirmed acetabular labral pathology electing to undergo conservative management defined as the refusal of surgical intervention. Based on a retrospective review of 894 patients presenting to clinic over a 10-year period, the investigators identified 22 patients with labral pathology that were treated non-operatively. Retrospective case control analysis was performed using outcome questionnaires administered to both surgical and non-surgical cohorts. The investigators found that patients with labral tears managed non-operatively appear to score highly on hip function outcome scores, preliminarily indicating there may be some benefit in using conservative management alone in the treatment of labral pathology. This is a 12-month prospective randomized control trial (RCT), which will enroll 121 subjects with evidence consistent with a tear of the acetabular labrum. Labral tear will be diagnosed by clinical exam and positive MRI findings. Subjects will receive conservative physical therapy treatment alone or arthroscopic surgical labral repair and physical therapy. The investigators anticipate that pain, range of motion, activity level, and functional performance, as judged by validated outcome measures and serial physical exams, will improve when compared to baseline. The investigators also anticipate that the level of response will be greater in the surgical treatment group than in the physical therapy group at 12 months. Our Primary Outcome is change in the modified Harris Hip Score at 6 months and 12 months. Secondary outcomes include changes in other outcomes measures (LEFS, HOS, NAHS, iHOT-33), patient satisfaction, and degree of improvement on physical exam, and the influence of OA severity (Outerbridge scoring) and location on the aforementioned outcome measures.

Official Title
-----------------
Arthroscopic Labral Repair Versus Physical Therapy for Tears of the Acetabular Labrum in Patients Age 40 and Older

Conditions
-----------------
Acetabular Labrum Tear, Femoro Acetabular Impingement, Hip Arthroscopy, Physical Therapy, Osteoarthritis, Hip

Intervention / Treatment
-----------------
* Procedure: Hip Arthroscopy Surgery with Acetabular Labral Repair (SPT group)
* Procedure: Physical Therapy Focused on the Hip and Hemi-pelvis (PT group)


Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Age 40 or greater: higher likelihood or undetectable OA on imaging Symptoms consistent with a tear of the acetabular labrum (at least one: catching, clicking, popping, pain with sitting, episodic pain, pain with hip flexion, adduction, and/or internal rotation): asymptomatic labral tears do exist in the general population however there is not definitive evidence to suggest treatment of asymptomatic tears is beneficial. Symptoms not due to some other acute process in or around the hip (including septic arthritis, osteonecrosis, hemarthrosis, iliotibial band syndrome, fractures of the femoral neck or head, fractures of the acetabulum, greater trochanteric pain syndrome, sacroiliac joint pain, piriformis syndrome, low back pain associated with hip pain and not knee nor acute low back injury): certain conditions are not treatable by either arthroscopy or physical therapy. Some of these conditions can be managed with physical therapy but not arthroscopy. Availability of hip radiographs and MRI: needed to assess eligibility Evidence on MRI of a tear of the acetabular labrum: documentation of acetabular labrum tear Willingness to undergo randomization and ability to understand and sign informed consent document: ability to understand study and consent willingly Exclusion Criteria: Less than 2 mm of joint space on standing plain anterior-posterior radiographs of the hip: indicative of severe osteoarthritic disease and the patient would benefit more from a total hip replacement Developmental dysplasia of the hip: distorted acetabular anatomy and biomechanics Kellgren-Lawrence Grade 4 changes: classified as large osteophytes, marked narrowing of joint space, severe sclerosis, and definite deformity of bone contour; indicative of severe OA Tonnis Grade 3 changes: classified as large cysts in the head or acetabulum, severe narrowing or obliteration of the joint space, severe deformity of the head, and necrosis; indicative of OA Unexpected pathology at the time of arthroscopy: source of pain less likely to due dysfunction of the labrum and more likely due to aberrant extra-articular biology Same site surgery: complex anatomy Back pain greater than hip pain or back pain associated with leg symptoms below the knee: source of pain less likely to be originating from the hip and more likely to be referred from the back/spine Back pain associated with positive neural tension signs e.g. positive slump test, positive SLR (straight leg raise), positive reflex changes or drop foot: source of pain less likely to be originating from the hip and more likely to be referred from the back/spine Knee pain greater than hip pain: source of pain less likely to be originating from the hip and more likely to referred from the knee Bilateral tears of the acetabular labrum: difficult to gauge patient progress after treatment Contraindication to surgery or physical therapy: cannot tolerate either treatment grouping Alternate form of PT for greater than 6 weeks: will negatively augment results. May affect recruitment.

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Hip Arthroscopy Surgery with Acetabular Labral Repair<br>Hip Arthroscopy Surgery with Acetabular Labral Repair | Procedure: Hip Arthroscopy Surgery with Acetabular Labral Repair (SPT group)<br>* Patients randomized to the SPT group provided consent for arthroscopic acetabular labral repair with femoroacetabular osteoplasty. As previously described in various technique publications from our group, the senior surgeon's (S.D.M.) hip arthroscopy technique includes intra-articular fluid distension for initial portal placement, puncture capsulotomy, autograft capsular augmentation if insufficient or degenerative labral tissue is encountered, intermittent traction, sparing use of electrocautery, and preservation of the chrondrolabral junction. All SPT patients underwent a standardized postoperative physical therapy protocol developed jointly by the senior author (a sports medicine fellowship-trained orthopaedic surgeon) and the physical therapists. Patients were kept weightbearing as tolerated on crutches for 6 weeks to maintain a level pelvis without lurching when walking and were instructed to avoid impact loading exercises for 6 months.<br>|
| Active Comparator: Physical Therapy Focused on the Hip and Hemi-pelvis<br>Physical Therapy focusing on the hemipelvis strengthening, including the lower back, lower abdominal core, quadriceps, hamstrings, and gluteal muscles. | Procedure: Physical Therapy Focused on the Hip and Hemi-pelvis (PT group)<br>* PTA patients were assigned a standardized, 24-week course of supervised, core-based PT. This course was designed in concert with physical therapists within our institution to help address symptoms of labral tear in patients older than 40 who had mild to moderate OA. Weeks 1 and 2 focused on normalizing gait, and weeks 3 through 24 focused on optimizing range of motion (ROM) while slowly integrating strength training. Unlike the prerandomization PT protocol, the PTA protocol was predominantly physical therapist-supervised (at least 1 in-person visit per week).<br>|

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change in mHHS Surveys From Preoperative to Various Postoperative Timepoints | Full Name of Outcome: modified Harris Hip Score (mHHS) Purpose: Validated Hip Patient Reported Outcome Measurements (PROMs) to assess the patient's functional outcomes post-surgery. Scale of mHHS: Min: 0 Max: 100 Higher score indicates better hip functionally. No subscores or subscales. The mean changes in scores required to achieve a minimically clinically important difference is 6.9. | Baseline (pre-operative), 3 months, 6 months, 12 months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Change HOS Surveys From Preoperative to Various Postoperative Timepoints | Full Name of Outcome: HOS--Hip Outcome Score. Purpose: Validated Hip Patient Reported Outcome Measurements (PROMs) to assess the patient's functional outcomes post-surgery. Scale of HOS: Min: 0 Max: 100 No standardized scoring categories (i.e. excellent, good, fair, poor). Higher score indicates better hip functionally. The mean change in HOS score required to achieve a minimally clinically important difference is 8.8. | Baseline (pre-operative), 3 months, 6 months, 12 months | 
| Change NAHS Surveys From Preoperative to Various Postoperative Timepoints | Full Name of Outcome: Non-Arthritic Hip Score (NAHS) Purpose: Validated Hip Patient Reported Outcome Measurements (PROMs) to assess the patient's functional outcomes post-surgery: Scale of NAHS: Min: 0 Max: 100 No standardized scoring categories (i.e. excellent, good, fair, poor). Higher score indicates better hip functionally. No subscores or subscales. No specific score to indicate a minimally clinically important difference. | Baseline (pre-operative), 3 months, 6 months, 12 months | 
| Change iHOT--33 Surveys From Preoperative to Various Postoperative Timepoints | Full Name of Outcome: International Hip Outcome Tool--33 Questions Purpose: Validated Hip Patient Reported Outcome Measurements (PROMs) to assess the patient's functional outcomes post-surgery. Scale of iHOT-33: Min: 0 Max: 100 No standardized scoring categories (i.e. excellent, good, fair, poor). Higher score indicates better hip functionally. No subscores or subscales The mean changes in iHOT-33 scores required to achieve minimally clinically important difference is 15.1. | Baseline (pre-operative), 3 months, 6 months, 12 months | 
| Change LEFS Surveys From Preoperative to Various Postoperative Timepoints | Full Name of Outcome: Lower Extremity Functional Scale (LEFS) Purpose: Validated Hip Patient Reported Outcome Measurements (PROMs) to assess the patient's functional outcomes post-surgery. Scale of LEFS: Min: 0 Max: 100 No standardized scoring categories (i.e. excellent, good, fair, poor). Higher score indicates better hip functionally. There is no designated improvement that is deemed to be a minimally clinically important difference | Baseline (pre-operative), 3 months, 6 months, 12 months | 
| Degree of Improvement on Hip VAS Pain Score | At routine follow-up visits patients will be asked to rate hip pain using the VAS (Visual Analog Scale) Score Min: 0--no pain Max: 10--worst pain experienced in their life Increments of 1. Categories: 1--3: mild pain 4--6: moderate pain 7--10: severe pain There is no reduction in VAS score that is considered a minimally clinically important difference. | Baseline (pre-operative), 3 months, 6 months, 12 months | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
HOS, Outerbridge, Acetabular Labrum Tear, Femoro Acetabular Impingement, Osteoarthritis, Hip Arthroscopy, Prospective, PROMs, mHHS, NAHS, LEFS, iHOT-33, RCT, Randomized Control Trial, Physical Therapy, PT, Osteoarthritis, Hip, Tonnis, Older than 40 years old