Pain and quality of life are impaired in adults with hip dysplasia undergoing periacetabular osteotomy: a systematic review and meta-analysis

Abstract

Purpose: In adults with hip dysplasia (i) evaluate pre to post- operative changes in pain, function and quality of life following Periacetabular Osteotomy (PAO); (ii) evaluate differences in pain, function and quality of life in those undertaking PAO and healthy controls; and (iii) evaluate differences in pain, function and quality of life in those with mild versus severe dysplasia, as defined by the Lateral Centre Edge Angle (LCEA) LCEA. Methods: A comprehensive, reproducible search strategy was performed on the following databases MEDLINE CINAHL, EMBASE, Sports Discuss, and PsychINFO from inception until 11th July 2019. Studies were eligible for inclusion if they used a hip-specific patient-reported outcome measure (PROM) and reported Level IV evidence or above. Participants: People aged 15 years and older with hip dysplasia undertaking PAO. Intervention: Studies utilising PAO surgery as primary intervention for Hip Dysplasia. The terms “Bernese Osteotomy” and “Ganz Osteotomy” were considered interchangeable with ‘Periacetabular Osteotomy’. Studies were ineligible if the PAO was reported to be a ‘rotational’ or ‘”curved” procedure. Comparator: Studies using sham treatment, no treatment or other treatment as the comparator/control treatment were included. We also included studies where no control group was present. Outcomes: Primary outcomes of interest were pain, function and quality of life. The hip-specific PROMs included: Hip Dysfunction and Osteoarthritis Outcome Score (HOOS), Western Ontario and McMaster universities osteoarthritis Index (WOMAC), the International Hip Outcome Tool (iHOT), the Copenhagen Hip and Groin Outcome Score (HAGOS), NAHS (Non-arthritic Hip Score), and the Oxford Hip Score (OHS). A modified version of the Downs and Black checklist was used to assess the quality of included studies. Quality Evaluation and Data Extraction was performed by two independent reviewers with any disagreements discussed in a consensus meeting and an independent arbitrator was employed when consensus could not be met. A hierarchy of PROMs was decided on between authors to prioritise data extraction where more than one had been used. The order of the hierarchy was based on the established level of validity and reliability of the PROM for young people with hip pain, and applicability to people with hip dysplasia undergoing PAO. In order of selection the hierarchy was HOOS, WOMAC, IHOT, HAGOS, NAHS, OHS. Results: The search yielded 4065 titles and abstracts for screening, with 51 studies included in the final analyses. The methodological quality scores ranged from 50% to 94%, with an overall mean (SD) rating of 71% (11.6%). Sample sizes of the PAO groups ranged from 16 patients to 391 patients. The ages for patients in the included studies ranged from 20 years to 45 years. All included studies used a PROM. Seventeen studies used the HOOS, 34 studies used the WOMAC, five studies used the iHOT, 4 studies used the HAGOS and 3 studies used the NAHS.Two studies, one prospective cohort study and a retrospective cohort study, compared subscale scores (pain, symptoms, activities of daily living (ADL), sport & recreation, and quality of life) pre-operatively versus post-operatively. For the pain subscale (Fig. 1) a significant improvement was found between pre-surgery and the one-year timepoint (SMC (95% CI): 1.50; 1.33 to 1.67) and this improvement was maintained at the two-year timepoint (1.43; 1.16 to 1.70). This also occurred in the symptoms subscale at one-year (1.21; 1.06 to 1.36) and two-years (1.08; 0.82 to 1.34); ADL at one-year (1.21; 1.06 to 1.36) and two-years (1.11; 0.98 to 1.23); sport & recreation at one-year (1.41; 1.25 to 1.57) and two-years (1.32; 0.88 to 1.75); and quality of life at one-year (1.38; 1.22 to 1.54) and two-years (1.31; 1.04 to 1.57). These results provide low-level evidence that patients experience clinical improvements across all subgroups at one year after PAO, compared to pre-surgery, and this is maintained at the two-year timepoint. Two studies compared outcomes between PAO patients and healthy participants, one high-quality prospective cohort study and one high quality cross-sectional study. Meta-analysis of the pre-operative time point showed significantly worse outcomes in the PAO group with large effect sizes across all subgroups. This included pain (Fig. 2) (SMD (95% CI): -3.84; -4.73 to -2.95), symptoms (-3.84; -4.36 to -3.29), ADL (-2.81, -3.89 to -1.74), sport & recreation (-3.47; -3.79 to -3.16), and quality of life (-4.10; -4.43 to -3.77). This result provides low-level evidence that PAO patients have significantly worse outcomes across all subgroups when compared to healthy participants. This occurs both pre-operatively and postoperatively and 6, 12 and 32 months. Conclusions: Before undergoing PAO surgery, adults with hip dysplasia have worse levels of pain, symptoms, ADL, sport and recreation and quality of life compared to healthy participants. These levels improve over two years following PAO, but do not reach the same level as their asymptomatic peersView Large Image Figure ViewerDownload Hi-res image Download (PPT)