Editorial Commentary: Revision Hip Arthroscopy in Patients Older Than 40 Has a Higher Rate of Conversion to Total Hip Arthroplasty—Get It Right the First Time,and the Second

Getting hip arthroscopy right the first time is critical to the overall patient outcome. This involves proper patient selection, with avoidance of arthritis, understanding the pathology of each hip, and properly executing the surgery. Care must be taken to restore labral function and preserve capsule function while accurately resecting pincer or cam impingement. While good results can be achieved in patients older than 40 years of age, an opportunity exists for improved optimization of clinical outcomes. Moreover, revision hip arthroscopy in patients older than 40 years of age has a higher rate of conversion to total hip arthroplasty. Again, get it right the first time, and carefully consider indications for revision hip arthroscopy in patients older than 40 years of age if there is a second time.     

Editorial Commentary: Spine Pathology May Compromise the Results of Hip Arthroscopy: Will Hip Arthroscopy Improve Low Back Pain?

Pathology of the lumbar spine and hip commonly occur concurrently. The hip–spine connection has been well documented in the hip arthroplasty literature but until recently has been largely ignored in the setting of hip arthroscopy. Physical examination and diagnostic workup of the lumbosacral junction are warranted to further our understanding of the effects of lumbosacral motion and pathology in patients with concomitant femoroacetabular impingement syndrome. An understanding of this relationship will better allow surgeons to counsel and preoperatively optimize patients undergoing evaluation and treatment of femoroacetabular impingement syndrome. Several studies have reported that patients with a previous lumbar arthrodesis undergoing hip arthroplasty have lower patient-reported outcomes and greater revision rates compared with patients without previous lumbar surgery, and similar to its effect on outcomes after hip arthroplasty, lumbar spine disease can compromise outcomes after hip arthroscopy. On the other side of the coin, hip arthroplasty has been shown to improve low back pain in patients with concomitant hip osteoarthritis. Can the arthroscopic treatment of nonarthritic hip pathology offer a similar result? We won't know unless we look.     

Hip Arthroscopy Update

The management of hip injuries in the athlete has evolved significantly in the past few years with theadvancement of arthroscopic techniques. The application of minimally invasive surgical techniques has facilitated relatively rapid returns to sporting activity in recreational and elite athletes alike. Recent advancements in both hip arthroscopy and magnetic resonance imaging have elucidated several sources of intraarticular pathology that result in chronic and disabling hip symptoms. Many of these conditions were previously unrecognized and thus, left untreated. Current indications for hip arthroscopy include management of labral tears, osteoplasty for femoroacetabular impingement, thermal capsulorrhaphy and capsular plication for subtle rotational instability and capsular laxity, lateral impact injury and chondral lesions, osteochondritis dissecans, ligamentum teres injuries, internal and external snapping hip, removal of loose bodies, synovial biopsy, subtotal synovectomy, synovial chondromatosis, infection, and certain cases of mild to moderate osteoarthritis with associated mechanical symptoms. In addition, patients with long-standing, unresolved hip joint pain and positive physical findings may benefit from arthroscopic evaluation. Patients with reproducible symptoms and physical findings that reveal limited functioning, and who have failed an adequate trial of conservative treatment will have the greatest likelihood of success after surgical intervention. Strict attention to thorough diagnostic examination, detailed imaging, and adherence to safe and reproducible surgical techniques, as described in this review, are essential for the success of this procedure.     

Editorial Commentary: Repeat Revision Hip Arthroscopy: Unaddressed Femoroacetabular Impingement,Labral Damage,and Capsular Deficiency Are Commonly Encountered

The increasing use of hip arthroscopy has been accompanied by an associated increase in revision hip arthroscopy. The results of revision surgery are generally inferior to primary hip arthroscopy. When revision hip arthroscopy fails, repeat revision hip arthroscopy may be indicated. Addressing the etiology of failure of the primary and first revision surgery is fundamental to achieving optimal outcomes in repeat revision cases. Unfortunately, poorly executed previous surgery is the leading etiology of failure, with unaddressed femoroacetabular impingement, labral damage, and capsular deficiency most commonly encountered during repeat revision surgery. Complex secondary soft-tissue procedures may be required to address capsular and labral deficiency from previous surgery. Despite clinically significant improvement in repeat revision cases, results are inferior to those after primary hip arthroscopy. The best opportunity for a patient to achieve an optimal outcome is a well-executed primary surgery.     

Editorial Commentary: Revision Hip Surgery After Arthroscopy—What Went Wrong? Are There Second Chances?

Hip arthroscopy allows minimally invasive treatment of femoroacetabular impingement (FAI) with labral tears. Over the last 2 decades, the indications and techniques for treatment of FAI have evolved, and complex pathology can now be treated arthroscopically. Short- and medium-term patient-reported outcomes demonstrate the reliability of hip arthroscopy for treatment of FAI, although a subset of patients fail to achieve desired results and require revision surgery. The indications for revision surgery after a primary hip arthroscopy are not well described in a large series, and most reviews focus on revision arthroscopy at the exclusion of open surgery (notably periacetabular osteotomy and total hip arthroplasty). Furthermore, patient-reported outcomes after these revision procedures have not been recently summarized.     

Editorial Commentary: Hip Arthroscopy—A Microcosm in the Evolution of Arthroscopy in Sports Medicine

Hip arthroscopy represents a microcosm in the evolution of arthroscopy within sports medicine. It has evolved right before our eyes over a condensed time frame with current-day techniques in arthroscopy and concepts in sports medicine. Early on, arthroscopy identified labral tears and other painful problems that had previously gone unrecognized and untreated because open procedures were rarely performed for these poorly defined conditions. The evolution of hip arthroscopy changed when femoroacetabular impingement was described and open surgical procedures were used for treatment. Open procedures for the hip, like the knee and shoulder before it, then evolved to less invasive arthroscopic methods. Techniques, technology, and understanding of hip disorders have all evolved simultaneously, resulting in a quickly changing landscape in the role of arthroscopy. And an improved focus has been gained on disorders other than femoroacetabular impingement that can lead to hip problems. This evolution is not novel because we have seen it in other joints, as well as among other general surgical procedures; most important, this evolution is not complete. Miles to go before we sleep.     

Editorial Commentary: Hip Arthroscopy Evolution and Causes of Failure

Hip arthroscopy use has grown as a result of expanding indications; improved imaging including higher resolution magnetic resonance imaging with stronger magnetic fields and the advent of 3-dimensional computed tomography revealing the nuances of hip joint morphology; increased specialized training; improvements in instruments and implants; a record of successful outcomes; and increased understanding of microinstability, focal acetabular undercoverage or occult dysplasia, indications for labral reconstruction and capsular plication, and, most of all, femoroacetabular impingement syndrome, the leading diagnosis for which hip arthroscopy is performed, in the orthopaedic community as well as the general medical and athletic communities. We now know that labral repair results in better outcomes than labral debridement, and evidence suggests that capsule closure leads to better long-term success. Osteoarthritis and its correlate, advanced age, result in inferior survivorship after hip arthroscopy, which is unsurprising; hip preservation surgery is not designed to treat irreparable cartilage damage. Association of female sex with hip arthroscopy failure requires additional investigation. More females undergo hip arthroscopy than males, and females initially present with greater disability. Females tend to have smaller alpha angles, greater femoral and acetabular anteversion, and lower center edge angles than males, consistent with increased prevalence of hip dysplasia. Thus surgeons indicating females for hip arthroscopy should be aware of atypical locations of cam lesions, borderline dysplasia, or ligamentous laxity, all of which must be appropriately respected at the time of surgery. With all of the improvements we have made in techniques, patient diagnosis and surgical indications, and our overall understanding of complex anatomy and a technically challenging surgery, we can speculate that our long-term survivorship will only improve. I await with interest the long-term outcomes we will see 10 years from today, with the addition of insight from patient-reported outcome measures to answer these questions with greater certainty.     

Editorial Commentary: Hip Arthroscopy for Femoroacetabular Impingement Syndrome in Adolescents Improves Outcomes: Don’t Forget the Young Guns

It has been said that youth is wasted on the young. This notion does not apply to the value that hip arthroscopy provides in managing hip pathology in adolescents. Multiple studies have shown the efficacy of hip arthroscopy as a treatment modality in the adult population for a multitude of hip pathologies, particularly femoroacetabular impingement syndrome. The implementation of hip arthroscopy in the management of femoroacetabular impingement syndrome in the adolescent population is on the rise. More studies illustrating favorable outcomes following hip arthroscopy in adolescents will serve to reinforce its utility as a treatment option for this population. Early intervention and preservation of hip function are of critical importance in a youthful and active patient population. As a word of caution, acetabular retroversion predisposes these patients to an increased risk of revision surgery.     

Abdominal Fluid Extravasation During Hip Arthroscopy

Hip arthroscopy has gained popularity in recent years as an alternative to open treatment for several conditions including bursitis, acetabular labral tears, synovitis, arthritis, extraction of loose bodies, and femoroacetabular impingement. Complications during hip arthroscopy are rare in the current literature, but reports include venous thromboembolism, peripheral nerve injury, septic arthritis, instrument failure, and various problems associated with joint traction. Extravasation of fluid into the abdomen during hip arthroscopy is another rare but known complication. We report an occurrence of extravasation of fluid into the abdomen during arthroscopic treatment of femoroacetabular impingement and our management of the condition postoperatively.     

Editorial Commentary: Hip Arthroscopy in Patients With Moderate to Advanced Osteoarthritis Shows Unpredictable Results

Hip arthroscopy is an effective surgical approach for the treatment of femoroacetabular impingement (FAI) syndrome with concomitant mild hip osteoarthritis (OA). However, in the FAI patients with moderate to advanced hip OA (Tönnis grade 2 or greater), whether hip arthroscopy could provide symptomatic relief or delay the need for an ultimate total hip arthroplasty surgery is controversial. The literature is heterogeneous and of generally lower quality evidence. Recent research reporting 10-year outcomes of hip arthroscopy in patients with hip OA shows 57% survivorship, and 78% survivor satisfaction. With unpredictable results, surgeons and well informed patients could hold some hope for a positive outcome after arthroscopy of an arthritic hip. As the Tönnis grading system shows poor interobserver reliability, surgeons may need to carefully consider their personal indications and resultant outcomes.     

Editorial Commentary: Excessive Femoral Retroversion and Increased Femoral Anteversion Has a Negative Effect on Hip Arthroscopy Outcomes: Symptomatic Extremes of Version Require an Osteotomy

With the rise in the prevalence of hip arthroscopy, patient selection and proper surgical execution are key to achieving excellent outcomes. As our understanding of femoral acetabular impingement grows, so does our surgical indications to achieve excellent surgical outcomes. Some impingement pathologies are amenable to arthroscopy alone and those with excessive version, dysplasia, Perthese, protrusio, and coxa-vara, or valga require an isolated or combined osteotomy. The version of the femur is known to be a significant source of impingement, and its impact on arthroscopic surgical outcomes has long been assumed to be inconsequential. Those that perform open and arthroscopic hip surgery understand this to be untrue, and arthroscopy alone cannot solve all of our impingement problems.     

Editorial Commentary: Hip Arthroscopy for Patients With Decreased Center-Edge Angle and Bipolar Cartilage Lesions Is Associated With Early Conversion to Total Hip Arthroplasty

The utilization of hip arthroscopy to treat femoroacetabular impingement has continued to grow year after year. Clinical studies and cost-effectiveness analyses have repeatedly shown the benefits of hip arthroscopy in improving quality of life, offering much promise to this patient population. Through years of research, a more comprehensive understanding of impingement pathologies has brought improving surgical techniques. However, predictors of poor outcomes are still not entirely understood. Although many patients attain significant relief, some patients do not attain meaningful improvement. Meaningful improvement can be found even years after hip arthroscopy, but this is a long road for patients who do not find sustained relief. Thus, as with defining appropriate indications for hip arthroscopy, it is equally important to identify factors that may instead suggest alternative treatment regimens for patients with hip pathology who may not benefit from arthroscopic intervention. However, rather than exclude large groups entirely based on the presence of certain factors such as increased age or arthritis, the goal should be to understand the nuances among patients in these higher-risk groups to identify those who may still find success with hip arthroscopy.     

Prior Hip Arthroscopy Increases Risk for Perioperative Total Hip Arthroplasty Complications: A Matched-Controlled Study

BackgroundArthroscopic hip surgery is becoming increasingly popular for the treatment of femoroacetabular impingement and labral tears. Reports of outcomes of hip arthroscopy converted to total hip arthroplasty (THA) have been limited by small sample sizes. The purpose of this study was to investigate the impact of prior hip arthroscopy on THA complications.MethodsWe queried our institutional database from January 2005 and December 2017 and identified 95 hip arthroscopy conversion THAs. A control cohort of 95 primary THA patients was matched by age, gender, and American Society of Anesthesiologists score. Patients were excluded if they had undergone open surgery on the ipsilateral hip. Intraoperative complications, estimated blood loss, operative time, postoperative complications, and need for revision were analyzed. Two separate analyses were performed. The first being intraoperative and immediate postoperative complications through 90-day follow-up and a second separate subanalysis of long-term outcomes on patients with minimum 2-year follow-up.ResultsAverage time from hip arthroscopy to THA was 29 months (range 2-153). Compared with primary THA controls, conversion patients had longer OR times (122 vs 103 minutes, P = .003). Conversion patients had a higher risk of any intraoperative complication (P = .043) and any postoperative complication (P = .007), with a higher rate of wound complications seen in conversion patients. There was not an increased risk of transfusion (P = .360), infection (P = 1.000), or periprosthetic fracture between groups (P = .150). When comparing THA approaches independent of primary or conversion surgery, there was no difference in intraoperative or postoperative complications (P = .500 and P = .790, respectively).ConclusionConversion of prior hip arthroscopy to THA, compared with primary THA, resulted in increased surgical times and increased intraoperative and postoperative complications. Patients should be counseled about the potential increased risks associated with conversion THA after prior hip arthroscopy.     

Editorial Commentary: Hip Arthroscopy Outcomes in Older Patients Can Equal Outcomes in Younger Patients With Proper Surgical Indications

Hip arthroscopy patients often present with clinical features that help broadly categorize them as the younger patient with femoroacetabular impingement, the microinstability- or instability-related patient, those patients with predominant peripheral compartment disease, and the older patient with femoroacetabular impingement plus peripheral compartment disease. Outcomes in older patients can equal outcomes in younger patients with proper surgical indications. Specifically, older hip arthroscopy patients do well in the absence of degenerative articular cartilage changes. Although some studies have suggested a potential for greater conversion rate to hip arthroplasty in an older age group, with proper patient selection, hip arthroscopy may lead to durable and significant improvements.     

Editorial Commentary: Not Repairing the Hip Capsule After Arthroscopy—What Were We Thinking?

There has been an exponential increase in attention paid to the hip capsule as it relates to arthroscopic procedures. Violation of the hip capsule during arthroscopy has clear biomechanical consequences for the joint, and evidence that the capsule should be repaired following most arthroscopic hip procedures, and also in revision settings, is becoming insurmountable.     

Editorial Commentary: The Indication and Technique of Iliotibial Band Release for External Snapping Hip During Hip Arthroscopy in Patients With Femoroacetabular Impingement Syndrome

Patients with femoroacetabular impingement syndrome (FAIS) often have extra-articular disorders, such as external snapping hip (ESH). We recommend that obvious ESH be addressed by endoscopic transversal iliotibial band (ITB) release during hip arthroscopy for FAIS because the residual serious snapping caused by ESH negatively affects the outcome of hip arthroscopy. However, for mild ESH without indications for severe trochanteric bursitis on magnetic resonance imaging, we still propose that physical therapy, extracorporeal shock wave therapy, or local injection be performed for pain relief. Surgical interventions for ESH including the Z-plasty technique and the modified Z-plasty technique for lengthening the ITB, as well as endoscopic cruciate or transversal incision in the ITB for release, have been reported with good results. Every technique has advantages and disadvantages, and we believe that surgeons should perform ITB release for ESH at the time of hip arthroscopy for FAIS based on their personal experience and inclination. In any case, excessive release of the ITB should be avoided. Finally, we wish to propose that more attention should be paid to the peri–greater trochanter (GT) space, an anatomic space between the ITB and the GT, which is similar to the subacromial space in the shoulder joint. Greater trochanteric pain syndrome (GTPS), related to the peri-GT space, is a spectrum of disorders, including trochanteric bursitis, abductor tendon pathology, and ESH. Precise diagnosis and proper procedures for concurrent GTPS during surgery may improve the outcome of arthroscopy in patients with both FAIS and GTPS.     

Editorial Commentary: Revision Hip Arthroscopy Provides Clinically Meaningful Improvements

Revision hip arthroscopy, like primary hip arthroscopy, is being performed more frequently. Questions remain regarding the clinical value of this surgical intervention, especially considering previous studies that demonstrate lower baseline patient-reported outcomes scores before and after surgery. Evaluation of the clinical utility and value of revision hip arthroscopy, and indeed all surgical interventions, need be performed using validated patient-reported outcomes in light of these clinically significant thresholds and changes, beyond just statistical differences.     

Editorial Commentary: “Dancing the Hip Away”—Does Joint Laxity Correlate With Worse Outcome in Dancers Undergoing Hip Arthroscopy for Femoral Acetabular Impingement?

Dancers have a disproportionately high prevalence of hip issues compared with other types of athletes. Many of these hip issues are complex: a cam and/or pincer impingement combined with a seemingly paradoxical borderline dysplasia, capsular laxity, and subsequent instability. Our experience as nonarthritic hip surgeons tells us that careful patient selection is critical for a successful outcome after the arthroscopic treatment of a dancer. But, there is little guidance in the literature on the management of this specific group of patients. We have studies that advise us to repair the labrum when possible versus performing labral debridement in female patients with predominantly pincer-type impingement and studies that support capsular plication and careful capsule closure in patients, predominantly female patients, with combined hip impingement and dysplasia or borderline dysplasia. However, few studies have examined predictors of outcomes after hip arthroscopy in dancers.     

Editorial Commentary: Hip Preservation and Opioids

Approximately one-third of patients undergoing arthroscopic hip preservation surgery for femoroacetabular impingement syndrome and labral tears are on preoperative opioid medications. The single most important predictor for prolonged chronic postoperative opioid use is preoperative use. Despite the well-documented high success rates in nonarthritic, nondysplastic individuals undergoing hip arthroscopy, up to half of those individuals on preoperative opioids may still be on opioids at 1 to 2 years of follow-up. Mental wellness disorders (e.g., depression, anxiety, substance abuse) significantly impact both pre- and postoperative pain, function, and activity in nearly all joint and general health outcome measures. Multimodal pain management strategies have shown excellent reduction in perioperative opioid utilization. Intraoperative techniques should strive for comprehensive true hip preservation: labral repair, accurate cam/pincer morphology correction, and routine capsular management. Objective, quantitative pain threshold and pain tolerance measurements may improve treatment decision-making, with better prediction of surgical outcomes. Future personalized health care may use a single individual’s mu opioid receptor (OPRM-1 gene) and a number of other genetic markers for pain management to reduce the need for traditional opioid medications. Is opioid-free hip arthroscopy possible? Absolutely. Will the opioid epidemic end? Yes, but we have a lot of work to do.