Editorial Commentary: Hip Arthroscopy—The Tissue-Friendly Evolution

The field of hip arthroscopy is saturated with low-level studies. A systematic review of these low-level studies provides low-level evidence favoring tissue-friendly restorative techniques such as labral repair and capsular repair over nonrestorative techniques such as labral debridement and capsulotomy. Iatrogenic complications such as nerve injuries and heterotopic ossification remain the most common complications of hip arthroscopy. This indicates that there is a further scope in improving the safety of hip arthroscopy. There is a need for innovative, well-designed benchtop and high-level clinical studies for rapid advancement in hip arthroscopy techniques.     

Editorial Commentary: The Importance of Capsular Closure Following Hip Arthroscopy—Leave No Trace: An Outdoorsman’s Ramblings

After a decade-long paradigm shift and an evidence-based enormous increase in the prevalence of hip arthroscopic procedures, hip capsular closure following arthroscopy, once a rare procedure, is now performed in the majority of surgical cases. This results from improved surgeon experience, refined surgical technologies and techniques and an explosion of research regarding stability of the hip joint. Once viewed as inherently stable, it is become clear that meticulous capsular management and closure can not only maintain joint stability but is a treatment for and/or prevents micro-instability. Recent research shows that hip capsular closure can improve outcomes and return to sport rates in the highest demand athletes having hip arthroscopy. Close the capsule!     

Editorial Commentary: Proximal Hamstring Injuries—Is the Hip to Blame?

There is a growing understanding of the relation between femoroacetabular impingement (FAI) and injury to adjacent structures. Patients with proximal hamstring pathology appear to have a high prevalence of underlying FAI. The kinetic chain phenomenon is a potential explanation of the high correlation between proximal hamstring injury and underlying FAI of the hip.     

Editorial Commentary: The Rise of Hip Arthroscopy: Temporary Trend or Here to Stay?

Hip arthroscopy has demonstrated a drastic rise in utilization in the past decade for the treatment of femoroacetabular impingement, labral tears, and early arthritic changes. During that time, there has also been a rise in the use of administrative claims databases that have allowed for the analysis of trends in surgical procedures. Multiple large administrative database analyses have been used to characterize the changing trends in hip arthroscopy, and the demand for these procedures has grown significantly at our own institution as well as nationally. Despite this rapid rise, not all patients may benefit from these procedures, and proper patient selection is key for optimal outcomes.     

Editorial Commentary: Hip Arthroscopy Capsular Management—Cut Your Cloth to Measure!

Microinstability of the hip is a relatively recent concept but one that is gaining increased acceptance. As our understanding of the factors that contribute to microinstability has increased, so too has our ability to identify “at-risk” patients, in whom a capsular repair should be considered after hip arthroscopy to achieve optimal results and avoid iatrogenic instability (dislocation or microinstability). However, each of our patients is different, and as such, we must be able to tailor our capsulotomies and repairs accordingly based on the bony morphology, capsular volume, and properties of the tissue.     

Editorial Commentary: The Wild,Wild West of Hip Arthroscopy—When to Pull the Trigger?

In our continued effort to refine the treatment algorithm of femoroacetabular impingement syndrome, duration of symptoms before surgery is receiving considerable attention by researchers. A (somewhat) negative linear correlation is being elucidated between outcomes and extent of damage at time of arthroscopy. Knowing this, it may be prudent in certain patient populations to recommend surgery earlier in the disease process in hopes of minimizing the amount of damage to the joint to delay or avoid the onset of arthritis.     

Editorial Commentary: The Importance of Capsular Closure in Hip Arthroscopy: Is There a Limit to the Benefit?

Capsular closure is an important concept in hip arthroscopy and should be performed in nearly all patients. However, in patients with stiff hips and borderline arthritic changes, leaving the capsule unrepaired or performing a partial repair in the setting of a T-capsulotomy could result in successful outcomes.     

Editorial Commentary: Myth Buster—Is Femoral Retroversion a Contraindication to Hip Arthroscopy in Femoroacetabular Impingement?

Hip arthroscopy can effectively address cam and pincer impingement by reshaping bone prominences or bone edges. However, hip arthroscopy cannot be used to correct severe bone torsion abnormalities such as acetabular or femoral retroversion. As a result, some surgeons contraindicate hip arthroscopy in patients with femoral retroversion absent correction of the torsion abnormalities. However, recent research has suggested that hip arthroscopy absent osteotomy, with a focus on labral preservation and thorough correction of underlying cam and pincer bony abnormalities, achieves positive outcomes. Still, although femoral retroversion should not be considered a contraindication for hip arthroscopy, patients should be carefully counseled about residual symptoms.     

Editorial Commentary: Hip Arthroscopy—Bimodal Bump and Volume Matters

In the experience of a high-volume hip arthroscopic surgeon with a referral practice, a bimodal age distribution could be common. Younger patients presenting with symptomatic hip pathology recalcitrant to nonoperative management may seek or be referred to high-volume surgeons, and older patients absent significant osteoarthritis may also be surgical candidates. Lower-volume hip surgeons could have higher complication rates, and it is incumbent on higher-volume surgeons to train upcoming colleagues as hip arthroscopy continues to grow.     

Editorial Commentary: What Irks a Hip Arthroscopist? Intraoperative Anchor Failure

Intraoperative suture anchor failure is a seemingly unavoidable event during hip arthroscopy and it can happen to the best of us. To date, biomechanical cadaveric studies saturate hip anchor failure literature with only one known, published in vivo investigation. We now know that intraoperative anchor failure is an uncommon occurrence that does not significantly vary between basic population demographics. However, we have only been provided with foundational knowledge, and our community must continue to expand upon the basics.     

Editorial Commentary: A-version to a Pain in the Butt—Structural and Dynamic Determinants of Posterior Hip Pain

Ischiofemoral impingement is becoming a more recognized source of buttock pain that occurs as the lesser trochanter of the femur approximates the lateral margin of the ischium. Abnormal bony structure and alignment of the hip joint and/or faulty dynamic movement patterns may decrease the ischiofemoral space and compress the structures that are found within the space, including the quadratus femoris, proximal hamstring tendons, and sciatic nerve. The ischiofemoral space is reduced by structural factors including an increase in femoral anteversion and femoral neck angle. Dynamic assessment of the hip region may include the Craig test and total rotational range of motion of the hip joint, as well as the ischiofemoral impingement test and the long-stride walking test. The combination of structural and dynamic assessment of the hip region may help determine the presence of ischiofemoral impingement and direct appropriate management of the condition.     

Editorial Commentary: Personalized Hip Arthroscopy Outcome Prediction Using Machine Learning—The Future Is Here

Machine learning and artificial intelligence are increasingly used in modern health care, including arthroscopic and related surgery. Multiple high-quality, Level I evidence, randomized, controlled investigations have recently shown the ability of hip arthroscopy to successfully treat femoroacetabular impingement syndrome and labral tears. Contemporary hip preservation practice strives to continually refine and improve the value of care provision. Multiple single-center and multicenter prospective registries continue to grow as part of both United States–based and international hip preservation–specific networks and collaborations. The ability to predict postoperative patient-reported outcomes preoperatively holds great promise with machine learning. Machine learning requires massive amounts of data, which can easily be generated from electronic medical records and both patient- and clinician-generated questionnaires. On top of text-based data, imaging (e.g., plain radiographs, computed tomography, and magnetic resonance imaging) can be rapidly interpreted and used in both clinical practice and research. Formidable computational power is also required, using different advanced statistical methods and algorithms to generate models with the ability to predict individual patient outcomes. Efficient integration of machine learning into hip arthroscopy practice can reduce physicians’ “busywork” of data collection and analysis. This can only improve the value of the patient experience, because surgeons have more time for shared decision making, with empathy, compassion, and humanity counterintuitively returning to medicine.     

Editorial Commentary: Hip Femoroacetabular Impingement Emotional Impact and Mental Health: An Arthroscope Can’t Fix Everything

Arthroscopic treatment of femoroacetabular impingement is increasingly common with established clinical success. As with other chronic injuries, there is an emotional impact that can affect recovery, particularly in competitive athletes. As this emotional aspect of injury is more recognized, it will be important to determine comprehensive means of treating both an athlete’s physical and mental health. It is important to establish preoperative expectations. For certain patients, psychological evaluation and treatment is indicated early in the diagnosis and recovery to ensure mental fitness, and this may be especially true for adolescents. A comprehensive and personalized approach to injury recovery is optimal.     

Editorial Commentary: Working Around the Coracoid—The Lighthouse to the Shoulder

Working around the coracoid has now become commonplace in arthroscopic shoulder surgery. No longer is there a safe side and a “suicide”; therefore, it is important to recognize the potential for neurovascular injury when surgery is performed about the coracoid. Although safe zones and distances are important, when more complex procedures are performed arthroscopically, direct visualization and identification of neurovascular structures is critical in avoiding iatrogenic injury.     

Editorial Commentary: The Forgotten Joint Score—Don't Compare Apples to Oranges

Patient outcomes have become focused on satisfaction with the end result. It is now appreciated that objective measurements are not the sole criterion for a successful surgical procedure. With the transition to evaluating patient-reported outcome measures, additional scoring techniques are being used to determine the best method for defining surgical success. The Forgotten Joint Score asks the simple question, “Are you aware of the joint that had surgery?” Essentially, does the patient have any sense that there has been surgery on the limb or joint? Although it has been validated as a reliable testing technique in specific surgical procedures, it has not been validated as a method of comparing 2 dissimilar surgical procedures. One must be selective and careful when using scoring methods. There are no data or validation to support the use of patient perception of the joint on surgical procedures that are divergent in their approach. Patient-reported outcomes such as the Forgotten Joint Score should not be used to compare procedures that are dissimilar in technique.     

Editorial Commentary: That’s Why They Call It Practice: The Arthroscopic Learning Curve

The learning curve for hip arthroscopy is steep. This progress represented a combination of both increased technical skill and, importantly, development of more refined surgical indications. In the end, safety and efficiency are aspects of a well performed operation, and the ultimate aspect is long-term patient outcome.     

Editorial Commentary: Segmental Hip Labral Reconstruction May Be Superior to Circumferential Reconstruction: Bigger Isn’t Better

Hip arthroscopic segmental and circumferential labral reconstruction show similar outcomes in short-term follow-up. Will bigger (circumferential reconstruction) eventually be largely a historical method? Bigger does not appear to be better, although some argue that segmental techniques inadequately restore the labrum’s function, incompletely treat the defect, and result in mismatch at the labral-graft junction, which is also a “weak spot” for future tears. Yet, others show that circumferential reconstruction is without clear benefit and adds additional anchors, complexity and operating room time and costs. The next phase of research on hip labral reconstruction requires evaluation of the numerous variables within the category of “reconstruction.” Today, a great number of different reconstruction techniques exist. Measuring a segmental defect can be challenging but is facilitated with methods such as the kite technique, use of a shoulder superior capsular reconstruction guide, or a pull-through method to simply avoid measuring. Graft options include ligamentum teres and iliotibial band, anterior and posterior tibialis, hamstring, fascia lata, autograft and allograft. Graft preparation, passage, and fixation techniques also vary widely. Finally, determining how much overlap with native labrum, ideal graft tension, or integrating the transverse acetabular ligament is more art than science. It’s time we begin to critically evaluate the differences in reconstructive techniques.     

Editorial Commentary: Returning to High-Impact Sports After Hip Arthroscopy: Are We Shooting Ourselves in the Hip?

There is a clear consensus in the literature that professional athletes exhibit high rates of return to sport following hip arthroscopy. As orthopaedic surgeons, we are well equipped to guide athletes back to the field after intra-articular hip injuries. However, returning to high-impact sports and playing through the pain can have implications on long-term health. Literature suggests that former elite athletes are at greater risk for reinjury and developing hip osteoarthritis compared with non-athletes. While it is incumbent upon us as orthopaedic surgeons to inform and advise our patients regarding the long-term consequences of return to sport after a hip injury, we recognize and enthusiastically support the passion that many athletes feel for the game and the vast benefits that they can derive from returning to the sport they love.     

Editorial Commentary: The Arthroscopist's Baton—Can Minimizing Motion Lead to Better Outcomes?

Unlike an orchestra conductor, whose fundamental goal is to bring a written score to life through exaggerated arm and body motion, the arthroscopist's goal is to enhance his or her surgical procedure by minimizing wasteful motion. So, the next time you are in the operating room observing or assisting with an arthroscopic procedure, do not just watch the monitor. Look at the surgeon's arm motion and see if you can distinguish between the maestro and the novice!