February 14, 2024

John Clohisy, MD, Wins Kappa Delta Award 

Originally published by AAOS

The 2024 Kappa Delta Elizabeth Winston Lanier Award was presented to the Academic Network of Conservative Hip Outcomes Research (ANCHOR) group for 20 years of research to improve the quality of care for adolescent and young adult patients suffering from the three most common pre-arthritic hip conditions: femoroacetabular impingement (FAI), developmental dysplasia of the hip (DDH) and residual Legg-Calve-Perthes Disease (LCPD). Their research helped the orthopaedic community better understand the basic pathophysiology of hip osteoarthritis (OA), disease natural history, diagnosis, surgical treatment and predictors of treatment outcomes for young patients who often live with hip dysfunction for years or even decades with eventual progression to advanced OA.

This award recognizes research in musculoskeletal disease or injury with great potential to advance patient care. To read more about the award, please click here.

OA is a common condition that affects 27 million Americans with costs that are projected to increase by $185.5 billion per year.[i] Hip OA is particularly problematic due to the associated disability. Over time, the pre-arthritic conditions of FAI, DDH and LCPD wear down the articular cartilage that covers the hip joint surface and lead to hip OA, which is associated with pain, limited function and reduced quality of life.

“In the early 2000s, the orthopaedic community lacked an understanding of pre-arthritic hip disease diagnoses and treatments. Variable patient age at presentation, lack of generalizable surgical treatments and limited clinical outcomes reporting for hip preservation procedures were major challenges,” said lead researcher John C. Clohisy, MD, FAAOS, Daniel C. and Betty B. Viehmann Distinguished Professor of Orthopaedic Surgery at Washington University in St. Louis. “Due to a lack of knowledge of pre-arthritic hip disease and a limited number of surgeons to treat these diseases, the average wait time for an accurate pre-arthritic hip diagnosis was three to five years. This was clearly an underserved patient population.”

Early contributions by Reinhold Ganz, MD, and his colleagues in Switzerland helped transform hip surgery with the introduction of new surgical techniques and refined concepts regarding the causes of hip OA. However, these refined concepts and surgical strategies were initially viewed as untraditional, unproven and technically challenging.

“We wanted to understand, investigate and implement Dr. Ganz’s concepts to advance the quality of care for these patients, and we established three goals as the basis of our research: improving the individual health care experience of the patient; improving the health of populations; and lowering per capita health care costs for populations,” said Dr. Clohisy.

The ANCHOR group, coordinated from Washington University, initially enrolled two cohorts (FAI-1 and PAO-1) totaling 3,168 surgical cases to detail population characteristics of FAI and DDH patients, and to investigate the safety and efficacy of surgical treatments. Rigorous, comprehensive data collection of clinical presentation, diagnosis, patient-reported outcome measures (PROMs), radiographic imaging, surgical procedure details and intraoperative disease classification was the foundation for subsequent investigations.  This robust dataset enabled the group to study several key performance indicators to provide quantitative measurement of improved patient outcomes.

KEY PERFORMANCE INDICATORS AND SUBSEQUENT FINDINGS

Timely Diagnosis: Define the patient population and educate orthopaedic surgeons
The ANCHOR group performed a series of foundational studies to describe the clinical presentation and epidemiology of patients with FAI, DDH and labral tears. Findings of the studies included:

• There is a predominance of DDH in young active females, who often present with significant hip dysfunction and symptoms including groin or lateral hip pain. Clinical presentation is accelerated with high activity levels and more severe deformity.
• Females with FAI have greater symptomatology and milder morphologic abnormalities while males have a higher activity level, larger morphologic abnormalities, and more extensive intra-articular disease. Both groups present with activity-related groin pain, and tend to have restricted hip range of motion and progressive symptoms over time.

Patient Satisfaction: Focus on responsiveness to patients’ needs
The ANCHOR group measured patient-reported satisfaction with standardized methodology to provide feedback on the patient experience associated with surgery for FAI. The findings included:

• FAI patients self-reported high overall satisfaction rates (>91%) and low rates of dissatisfaction (>9%). Longer-term mean 10-year follow up of the FAI-1 cohort was recently completed (unpublished data) and demonstrated maintenance of these high satisfaction rates (91%).
• Most patients studied who underwent PAO surgery demonstrated marked clinical improvement and returned to their sport, and only a small percentage had activity limitations from surgical hip symptoms (<11%). Overall patient satisfaction in PAO patients was also consistently over 90%.

Treatment Indication: Causes of hip preservation failure and innovations in surgical techniques
These studies aimed to identify appropriateness in patient selection and precise surgical technique. The findings included:

• Hip arthroscopy procedures are best utilized in the treatment of FAI with accessible FAI morphology. Alternatively, outcomes of isolated hip arthroscopy in the setting of acetabular dysplasia or advanced articular disease are not favorable.

Complication Risk: Ensuring safety for high-quality care
The initial literature on surgical procedures in the young population was not standardized and lacked risk and complication reporting. The group analyzed the safety of PAO, hip arthroscopy and surgical hip dislocation. The findings included:

• The complication risk is very acceptable and ranges from 1 to 5%, depending on the procedure.
• Permanent disability related to any of these procedures is less than 1%.

Effectiveness: Using PROMs to compare preoperative and follow-up outcomes
Early skepticism among the orthopaedic community related to the diagnosis of FAI, its association with hip OA, indications for surgery and efficacy of surgery required critical investigation of these new concepts. The findings included:

• Preoperative PROM score was a strong, highly significant predictor of all outcomes. More recent analyses have determined that competitive athletes have superior outcomes and lower failure rates compared to non-athletes (after controlling for important covariates). For FAI surgery, a lower risk of clinical failure was associated with participation in competitive athletics (p=0.01) and male gender (p<0.001).
• Longer chronicity of preoperative symptoms, patients over 40 years old requiring acetabular microfracture, and revision surgery are all independently associated with inferior clinical outcomes. Subgroup analysis of adolescent patients identifies females, mild cam FAI deformities and lack of sports participation to be associated with higher rates of treatment failure.

Diagnosis and Length of Stay: Timeliness, accurate evaluation/diagnosis and cost|
The ANCHOR group developed a consensus document to standardize radiograph evaluation of the young adult hip and more recently have emphasized the important role of 3D imaging. This work included:

• A comprehensive review of radiographic technique and image interpretation that has served as a cornerstone contribution for surgeons, radiologists, radiology technicians and orthopaedic/radiology trainees.
• Three-dimensional imaging plays a fundamental role in the evaluation of young adult hip disorders.
• Low-dose computed tomography (CT) scanning is an excellent tool to precisely determine acetabular and femoral morphology as well as femoral version.

“Over the past 20 years, access to quality care for young patients with pre-arthritic hip disease has markedly improved” said Dr. Clohisy. “We now have surgeons and health care teams who can deliver a comprehensive approach to manage the full spectrum of pre-arthritic hip disease. While we’ve made great strides, we're continuing to improve by better defining and diagnosing the conditions, determining the best indications for surgery and optimizing our surgical techniques.”