Summary

The purpose of this study is to evaluate the inter-observer agreement of surgical treatment decisions based on hip/pelvis plain radiographs between adult reconstruction- and sports medicine-fellowship trained orthopedic surgeons.

Abstract

Background

Arthroscopic hip preservation and total hip arthroplasty surgeons have both been shown to have excellent subjective patient-reported and objective surgeon-measured short-, mid-, and long-term outcomes for non-arthritic and advanced arthritic diagnoses, respectively. The “in-between” case of mild to moderate hip arthritis is controversial in that patients have too much arthritis for an arthroscopy and not enough arthritis for an arthroplasty. The purpose of this study is to evaluate the inter-observer agreement of surgical treatment decisions based on hip/pelvis plain radiographs between adult reconstruction- and sports medicine-fellowship trained orthopedic surgeons.

Methods

Plain hip/pelvis radiographs of 12 subjects with hip pain of varying ages and levels of osteoarthritis were evaluated by sports medicine surgeons with a hip preservation surgery clinical practice and adult reconstruction surgeons. Participants were to assume that all subjects had attempted non-surgical treatment without success, and desired surgical treatment of either arthroscopy or total hip arthroplasty. Each surgeon selected imaging features (arthritis level [Tonnis]) and surgical treatment (arthroscopy, total hip arthroplasty) for each case. Participants were told the patient’s sex and age. Surgeon responses were analyzed in sub-groups identified by patients with minimal arthritis (Tonnis 0/1) and advanced arthritis (Tonnis 2/3). Agreement was evaluated via the kappa coefficient.

Results

Nineteen surgeons (8 adult reconstruction, 11 sports medicine) participated in the survey. There were no significant differences between Adult Reconstruction and Sports Medicine surgeons in age, years in post-fellowship practice or number of total hip surgeries per year. In the minimal arthritis group, Sports surgeons recommended hip arthroscopy at a significantly higher rate than reconstruction surgeons (32.5% vs 9.5%, p < .01). Sports and reconstruction surgeons showed only fair agreement (kappa 0.21-0.40) on the recommendation for hip arthroplasty and only moderate agreement (kappa 0.41-0.60) on the recommendation of hip arthroscopy. In the advanced arthritis group, there was no statistically significant difference between sports and reconstruction surgeons in their recommendation for total hip arthroplasty. Sports and reconstruction surgeons showed good agreement (kappa 0.61-0.80) on the recommendation for hip arthroplasty and very good agreement (kappa >0.80) on the recommendation against arthroscopy.

Conclusions

The primary outcome of this study was moderate to good agreement between Sports Medicine and Adult Reconstruction surgeons in selecting either hip arthroscopy or arthroplasty for the “in-between” patients with mild to moderate hip arthritis. While the study has a small number of participants, radiographic characterization and recommended surgical treatments differ between sports medicine and adult reconstruction surgeons and consensus and greater agreement is needed for optimal patient care.