**6. Other factors**

The decision between hip preservation surgery and THA for borderline cases is also influenced by the following factors barely addressed in medical literature: patient expectations, abnormalities in additional hip layers, contra-lateral hip disease, profession and physical activities, commitment to rehabilitation, family support, chronicity of pain, opioid use, comorbidities, and physician-related aspects. Despite the lack of scientific evidence on those factors, the authors of the current chapter decided to share their impressions after combined decades of experience on deciding if conservative treatment, hip preservation surgery, or THA would be the most appropriate.

The concept of hip layers is very useful for the orthopedic surgeon to identify and organize diagnosis in patients with hip abnormalities, and to relate those to the patient expectations. The hip abnormalities can be categorized in the following layers: osteochondral, capsulolabral, musculotendinous, neurovascular, and kinematic chain. The fifth layer represents the link between the hip, pelvis, lumbar spine, CORE and distal lower extremity. Most patients with hip symptoms will have problems in more than one layer, which can be related or unrelated. For example, patients with acetabular dysplasia often have associated gluteus medius and minimus tendinitis as result of excess work required from the abductors. The correction of the osseous abnormalities may or not result in improvement of the conditions in other layers. Each diagnosis and potential improvement or not with surgery must be shared with patients, so they can understand the decision process and be aware that some problems/symptoms may not get better with surgery. Most patients believe their hip problem can be cured and expect to be asymptomatic at the end of treatment. This outcome is unlikely for hip pathologies and patients will have a more realistic expectation if they are instructed before surgery about a multilayer diagnosis.

The hip joint is the center of human body movement, and functional hips are required for most activities of daily living. When both hips become symptomatic, life can become particularly challenging. In most hip preservation surgeries, the operated hip will require at least 3 to 6 months of protected activities, and the non-operated hip may become more symptomatic. A THA is usually more foreseeable under the rehabilitation point of view and is a better option for most patients with bilateral hip symptoms and borderline case between preservation and THA. Patient profession is another important factor in borderline cases. Consider the following clinical scenario: a 50-year-old male farmer with symptomatic labral tear and grade 1–2 osteoarthritis with Harris hip score of 60 and Oswestry score of 20%, associated contra-lateral hip and low back pain, need to return to work in weeks after surgery, and average of 2 miles walked daily. Even if imaging studies do not contra-indicate hip preservation surgery, this patient's profession and clinical scenario indicate that a THA might be a treatment option for him. Conservative treatment or hip arthroscopy could be a more appropriate option to an office worker with the same clinical scenario except for the profession. Per our experience, non-athlete patients with higher physical demands on their job tend to be less satisfied with hip arthroscopy and preservation surgeries. Not only the profession and work are to be considered, but also the physical requirements of leisure and family requirements. Commitment to rehabilitation and family support are factors often overlooked by patients and physicians before making a treatment decision for hip pathologies. Because of the demands involved with recovery processes after hip surgery, the patient may be limited for regular home tasks and requires the support of family. Socioeconomic factors are important to consider when deciding between hip preservation surgery or THA. Hip preservation surgery requires

#### *Decision Making in Borderline Cases between Hip Preservation and Reconstruction Surgery DOI: http://dx.doi.org/10.5772/intechopen.104765*

months and sometimes years to reach the maximum improvement, particularly in patients with multilayer hip problems.

The chronicity of hip pain experienced prior can play a role in deciding which treatment route to pursue. Garbuz et al. found that patients who waited more than 6 months before THA had a 50% decrease in the odds of achieving a better-thanexpected outcome as measured by the Western Ontario McMaster Universities Osteoarthritis Index (WOMAC) when compared to patients with 0–6 months delay [59]. Moreover, each additional month delay after 6 months was associated with 8% additional decrease in odds of achieving a better-than-expected WOMAC score [59]. Similar decreases in clinical outcome scores have been shown with increased preoperative duration of pain in arthroscopic patients. Kunze et al. reported that hip pain from femoroacetabular impingement for 12–24 months in duration preceding surgery was associated with worse postoperative outcomes compared to hip pain with a duration of 3–6 months before surgery [60]. Basques et al. reported similar results: patients with femoroacetabular impingement and more than 2 years of preoperative hip pain have significantly higher 2-year VAS-pain scores, along with significantly lower HOS-ADL, HOS-SS, and mHHS scores after hip arthroscopy [61].

Preoperative opioid use has been associated with less favorable postoperative outcomes after hip preservation surgery and THA. Weick et al. reported that THA patients with >60 days of preoperative opioid use, compared to opioid-naïve patients and patients with <60 days preoperative use, had increased odds of readmission at 30 days postoperatively (OR = 1.46, CI: 1.36–1.57) and needing revision surgery at 1 year (OR = 2.19, CI: 1.84–2.62) [62]. The odds of requiring revision surgery was found to be even greater by the 3-year mark (OR = 1.90, CI: 1.64–2.20) [62]. Zusmanovich et al. reported that patients who regularly used opioids for isolated hip pain within 6 months before hip arthroscopy had higher 1-year postoperative VAS scores compared to opioid-naïve patients (6.1 ± 3.1 vs. 1.5 ± 1.6, respectively) (p < .001) [63]. At 2-year postoperatively, mHHS was significantly lower in the study cohort of opioid users compared to opioid-naïve group (55.4 ± 19.6 vs. 80.4 ± 12.8, respectively) (p < .001) [63]. Nazzal et al. reported that 2501 hip arthroscopy patients who preoperatively were taking >5 oral morphine equivalents had statistically significantly increased odds of prolonged opioid use (i.e. ≥2 opioid prescriptions) in the 6- to 12-month postoperative period (OR, 10.45; p < 0.001) compared to 19,633 patients who took fewer oral morphine equivalents [64]. These patients were also shown to have increased odds of 3-year revision surgery (both hip arthroscopy and total hip arthroplasty: OR = 2.14, p < 0.001 and OR = 2.04, p = 0.001, respectively) [64]. The reversibility of the negative effects of opioid use in hip surgery results has not been defined yet, i.e., does a patient on chronic opioid use benefit from stopping it before a hip surgery? Until further evidence is available, patients might be instructed to work on strategies along with their pain management providers aiming to decrease or stop opioid use before elective hip surgery.

The presence of additional medical conditions may influence the outcome and success of hip reconstruction and preservation procedures. Loth et al. reported that THA patients with ≥1 comorbidity on the Charlson comorbidity index (CCI), pain from other joints, or BMI > 30 kg/m2 did not have significantly different postoperative improvements in pain and joint function when compared to THA patients with no comorbidities [65]. However, patients with comorbidities were still found to have lower general health scores (mean of 39.1 vs. 44.9) as measured by the Short Form-12 (SF-12) (p < .001) [65]. Mannion et al. reported that greater comorbidity was associated with increased odds of a complication and (independently) slightly worse patient-rated outcome 12 months after THA [66]. Fewer studies have investigated the relationship between comorbidities and hip arthroscopy outcomes. Perets et al. reported diabetes mellitus is not significantly associated with worse outcomes in hip arthroscopy cases for treatment of femoroacetabular impingement and labral tears [67]. The psychological status and psychiatric conditions are also to be considered in patients with chronic hip pain. Patients often enter in a pain cycle bolstering the effects of hip pain and limitation in their lives. Sochacki et al. reported that patients with minimal or mild depressive symptoms have better preoperative and postoperative outcomes and are more likely to obtain substantial clinical benefit from surgery than patients with moderate to severe depressive symptoms [68]. Martin et al. reported a high prevalence of patients with symptoms of depression (28%) and severe depression (11%) among 781 patients who underwent hip arthroscopy [69]. The high prevalence of depression in patients with chronic hip pain reinforces the importance of optimal hip function for a healthy mental status. Buller et al. reported the existing diagnosis of depression, dementia, or schizophrenia in THA patients is significantly associated with increased odds of adverse effects after THA (i.e. wound complication, shock, acute renal failure, etc.) [70]. Consultation with a pain psychologist is helpful for patients with chronic hip pain to address the mind effects of chronic pain, and to identify patients whose psychological status may impede improvement after hip surgery.
