All right. Thank you. It's an honor to be here today. So I have no disclosures relevant to this talk. So I'm going to talk about why the field of hip preservation is an ideal case study for the impact of patient reported outcomes in clinical medicine. And we'll discuss some of the changes that we've seen in hip preservation as a result of PROs. First, what is my definition of hip preservation? I would say it's all the interventions, both nonoperative and operative, which attempt to preserve a native hip and prevent or delay a total hip replacement. The most common surgeries that we perform in hip preservation are hip arthroscopy and periacetabular osteotomy of the pelvis. While we've long known that there are multiple pediatric disorders that lead to early hip arthritis, specifically SCFI and Perthes, it was only in 2003 that Dr. Gantz first described femoral acetabular impingement as a reason for early hip arthritis. That's less than two decades ago. And since the beginning of FAI, there has been an exponential increase in the number of procedures performed for this diagnosis. More recent literature has suggested that recently we might have found a steady state, but we're still performing hip arthroscopies in particular at a very high rate. So when I think about the evolution of patient outcomes in hip preservation, I think about them in four different generations. The first generation asked, can we successfully save the hip or not after some of our interventions? Second generation, can we delay or prevent a hip replacement? Third generation, can we do that with a more minimally invasive surgery? And then fourth generation, where we are now, can we improve patient quality of life, restore function, relieve pain, and improve patient satisfaction? So first generation outcomes. It was in 2001 that Gantz and his colleagues again described what is now the modern technique for surgical hip dislocation. This was based on their anatomical study of the femoral circumflex artery. And that surgical hip dislocation allows for full access to the intra-articular pathology of the joint. But it wasn't until Gantz was able to prove a 0% incidence of avascular necrosis of the hip after this procedure that it gained popularity. This was a far cry from their previously reported 18% incidence of avascular necrosis after a surgical hip dislocation. So in answer to the first generation outcome question, yes, we can preserve the hip after surgical intervention. So that led to the second generation outcomes. Can we delay or prevent a hip replacement? And this was determined postoperatively mostly with radiographs. And there are a number of radiographic measurements reviewed, 24 in this review alone. And then the end point of a patient getting a subsequent hip replacement was the determination of success or non-success. So after doing this type of research for the second generation outcomes, we were able to answer yes, with surgical treatment for femorostabular impingement, we can delay or prevent a hip replacement. And then came the third generation outcomes. Can we do that with a more minimally invasive surgery? So at the time, the treatment for femorostabular impingement included surgical hip dislocation, anterior mini approach to the hip, and then the burgeoning hip arthroscopy. This research allowed us to see with end points of hip replacement and revision surgery that equal outcomes were achieved with the less invasive hip arthroscopy procedure. And this correlated with a shift not only in our literature but in our practice of more arthroscopic treatment instead of open. So the third generation outcomes allowed us to see that open and arthroscopic surgeries for FAI had similar efficacies. Arthroscopic surgeries had fewer complications than the open surgeries. But it wasn't until the fourth generation outcomes that allowed us to see that arthroscopy showed superior general health-related quality of life scores. And so that brings us to our fourth generation, our current generation of patient-reported outcome measures. Promises are necessary to truly understand our patients and whether or not they're getting better after our interventions. Dr. Stedman once eloquently stated, if a patient does not think he or she is getting a great result, then he or she is not. Currently, there are more than 20 different patient-reported outcomes in the hip literature, and the mean number of PROs per published paper is 3.2. As we've heard, PROMIS was developed in 2004 by the NIH with the goal of creating a standardized outcome measure that could be applied not only to one subspecialty but across a large spectrum of subspecialties. In addition, they added computerized adaptive testing, which reduced redundant questions. And in fact, the PROMIS score has been validated as having a high correlation and low test burden compared to our legacy patient-reported outcome scores in the hip literature. Now, I mentioned we have a lot of patient-reported outcomes, but what do those numbers mean? And that's where the importance of MCID, PASS, and SCB, or substantial clinical benefit, really tell us how that patient is doing clinically. There have been a number of questions and controversies in hip preservation, which we've been able to answer now because of PROs in just the past two decades. When hip arthroscopy began, debriding the labrum was standard of care, but patient-reported outcome measures showed that labral repair patients did better than labral debridement, and now labral repair is definitively the standard of care. The next question was, should we repair or reconstruct the labrum? And sure enough, patient-reported outcome measures have shown that there's actually no difference in outcomes after each of these procedures, and because the outcomes are equivalent, it is safe to support doing the procedure that's indicated on a case-by-case basis. What about iliopsoas lengthening? Once again, this was a common practice in early hip arthroscopy, but this recent multicenter study demonstrated that patients who had an iliopsoas lengthening had poorer patient-reported outcomes postoperatively, and this group of authors supports that you should not release the psoas tendon during hip arthroscopy. And what do we do about grade 4 chondromalacia lesions in the acetabulum? Well, patient-reported outcome measures after either chondroplasty or microfracture are actually the same, so I interpret this to mean we should do the less invasive procedure, which is abrasion chondroplasty. And then, of course, the continuing debate of capsule closure or not closure, and I would argue it's no longer much of a debate, but there are a few papers out there showing no significant difference between capsule closure and non. I would argue that there's a growing body of literature supporting capsule closure results and increased patient-reported outcomes after surgery, and so the conclusion here is that complete capsule closure is better for patients long-term. PROs have also allowed us to answer the question, how long does it take to get better after hip arthroscopy? And these authors found that many patients achieve improved outcomes at about three months, but continued outcome improvement will continue for about two years after surgery. And here encourages our use of multi-institutional consortiums because this allows us to combine many of our PROs and come to these answers much more quickly. So in summary, the field of hip preservation itself has proven to be an ideal case study for the impact of patient-reported outcomes in just two decades alone. And patient-reported outcomes in hip preservation have really changed our practice, and I believe will continue to do so with the implementation of improved PROs. Thank you.

hip preservation

patient-reported outcomes

clinical medicine

total hip replacement

evolution of PROs