Editorial Commentary: Complete Capsular Closure During Hip Arthroscopy Provides the Most Reliable and Durable Outcome . . . Capsule Closed . . . Case Closed!

The management of the hip capsule has been a recent area of controversy in hip arthroscopy. Over the past 5 years, there has been mounting biomechanical and clinical evidence that complete capsular closure is an important step to achieve the best and most durable outcome from hip arthroscopy. Numerous studies in the laboratory have shown that repairing the capsulotomy during simulated hip arthroscopy establishes normal hip biomechanics. Multiple studies have also reported improved clinical outcomes and less conversion to total hip arthroplasty in patients undergoing capsular repair. We have published that patients improve after revision hip arthroscopy for repair of capsular defects. I think it is safe to say that complete capsular closure after hip arthroscopy is becoming the standard of care in our field.     

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.     

Hip arthroscopy in osteoarthritis. A review of 68 patients

BACKGROUND AND AIMS: A few studies have investigated therapeutic effect of hip arthroscopy in osteoarthritis, and therefore the use of hip arthroscopy in osteoarthritis has remained controversial. The aim of this study was to evaluate diagnostic and therapeutic aspects of hip arthroscopy in primary osteoarthritis. MATERIAL AND METHODS: During a time period from 1995 to 1999, a total of 68 patients had an arthroscopic evaluation of primary hip osteoarthritis at the P?ij?t-H?me Central Hospital, Lahti, Finland. The mean (range) follow-up was 1.3 (0.3 to 4) years. Arthroscopy was diagnostic in 38 (56%), while six (9%) patients received either long-lasting anaesthetic or prednisolone, and in 24 (35%) debridement was possible. Partial synovectomy was performed in two (3%). RESULTS: Three months after the arthroscopy, 49 (72%) patients reported that their hip pain had decreased. One year after the arthroscopy, 18 (26%) patients stated that their hip pain was less pronounced than before the arthroscopy. The severity of hip osteoarthritis in preoperative x-rays correlated significantly (p = 0.035) with the subjective result: the milder the osteoarthritis, the more often patients reported that their hip pain had decreased after arthroscopy. No association was observed between age, sex, modified Outerbridge grade of chondropathy, or whether a debridement was done or not and the symptomatic relief after the arthroscopy. CONCLUSIONS: Hip arthroscopy with or without debridement of loose cartilage may, at least temporarily, reduce the pain of mild or moderate osteoarthritis of the hip. Still, repeated arthroscopies had no therapeutic effect.     

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.     

Abdominal Compartment Syndrome After Hip Arthroscopy

As hip arthroscopy becomes a more common procedure, more complications may occur. We present a case of abdominal compartment syndrome resulting from fluid extravasation in a 42-year-old man who underwent routine hip arthroscopy for femoral acetabular impingement. He had not had previous surgeries to that hip, and arthroscopy was performed in the supine position. After adequate distraction, arthroscopy was performed with an automated pressure- and flow-controlled pump with the pressure maintained between 40 and 60 mm Hg. We performed debridement of a degenerative tear of the anterosuperior labrum, removal of a pincer lesion, and a psoas tenotomy through a capsular window. A distended abdomen was noted on drape removal, and the patient required decompressive laparotomy for abdominal compartment syndrome. Extravasation of arthroscopy fluid is a potentially devastating complication during hip arthroscopy, and there should be careful monitoring by the surgeons, anesthesiologists, and operating room staff.     

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.     

Emergent hip arthroscopy: life-saving intervention for septic hip and secondary multiorgan failure

This article describes the case of a 27-year-old female athletic trainer who presented to the emergency department in acute renal failure with rhabdomyolysis and disseminated intravascular coagulation following a brief onset of right hip pain and staphylococcal facial infection. Despite the absence of fever, peripheral leukocytosis, or organisms on gram stain from emergent joint aspiration, magnetic resonance imaging revealed a large hip effusion; a presumptive diagnosis of septic hip was made. Emergent hip arthroscopy was performed in the middle of the night within 3 hours of presentation. Minimally invasive, high-volume irrigation and debridement was rapidly performed using dual-portal arthroscopy. Although this approach required prolonged critical respiratory and hemodynamic support, the patient recovered from a life-threatening situation not often seen by arthroscopic or sports medicine surgeons. The unusual diagnosis of staphylococcal hip sepsis with multifocal dissemination was established, as was an atypical but important indication for emergent hip arthroscopy. Although generally implemented to improve quality of life, this case represents the use of hip arthroscopy to increase its quantity as well. Hip arthroscopy may have an emergent indication with life-saving potential.     

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.     

髋关节镜的临床应用进展

髋关节镜技术近20年飞速发展,在髋关节损伤诊断治疗领域的作用愈加显著。以往通过X线、CT或MRI等检查无法确定的髋关节病损也可通过髋关节镜检查得到较为明确的诊断,该技术逐渐成为髋关节疾病诊断的金标准。目前,髋关节镜检查入路主要有外侧入路、前侧入路、后外侧入路,应用范围主要包括盂唇撕裂、股骨髋臼撞击症、圆韧带损伤、软骨损伤、滑膜疾病、关节内感染、关节内游离体等。髋关节镜技术是一项综合性技术,其优点得以良好体现须手术者熟悉掌握该技术的适应证、禁忌证以及手术操作方法,必须在术前进行细致的物理检查及影像学检查,在术后进行合理有效的康复功能训练。     

Hip arthroscopy in the pediatric population

Hip arthroscopy has obvious advantages over arthrotomy in the pediatric population. Hip arthroscopy, used as a diagnostic or therapeutic tool, is significantly less invasive than arthrotomy and allows for quicker recovery and return to activities. In addition, arthroscopy avoids dislocation of the femoral head and the corresponding risk of osteonecrosis. Current indications for hip arthroscopy in pediatric patients include septic arthritis, labral disorders, slipped capital femoral epiphysis, and Legg-Calvé-Perthes disease. The role of hip arthroscopy in the pediatric population will continue to expand because of its attractiveness as a less invasive option for evaluating the hip.     

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: Is Back Pain Killing Your Hip Arthroscopy Outcomes?

The identification of factors associated with inferior postoperative outcomes after hip arthroscopy is critical as we try to further clarify indications for hip arthroscopy. Recent arthroplasty studies have shown worse outcomes after hip and knee replacement in patients with comorbid joint and spine pain. Recent evidence has shown this to be true in patients undergoing hip arthroscopy as well. This evidence helps surgeons counsel patients better preoperatively and manage their expectations postoperatively. Patients with comorbid joint and spine pain should expect improvements in pain and function after hip arthroscopy; however, the overall functional outcomes are worse than those in patients without these comorbid conditions.     

Arthroscopy of the hip in patients following joint replacement

Arthroscopy of the native hip is an established diagnostic and therapeutic procedure. Its application in the symptomatic replaced hip is still being explored. We describe the use of arthroscopy of the hip in 24 symptomatic patients following total hip replacement, resurfacing arthroplasty of the hip and partial resurfacing (study group), and compared it with arthroscopy of the native hip in 24 patients (control group). A diagnosis was made or confirmed at arthroscopy in 23 of the study group and a therapeutic arthroscopic intervention resulted in relief of symptoms in ten of these. In a further seven patients it led to revision hip replacement. In contrast, arthroscopy in the control group was diagnostic in all 24 patients and the resulting arthroscopic therapeutic intervention provided symptomatic relief in 21. The mean operative time in the study group (59.7 minutes (35 to 93)) was less than in the control group (71 minutes (40 to 100), p = 0.04) but the arthroscopic approach was more difficult in the arthroplasty group. We suggest that arthroscopy has a role in the management of patients with a symptomatic arthroplasty when other investigations have failed to provide a diagnosis.     

Editorial Commentary: Doctor,Will My Contralateral Hip Surgery Go as Well as the First One?

Patients presenting with bilateral symptomatic femoroacetabular impingement for staged bilateral hip surgery or developing pain in their nonoperated hip after hip arthroscopy are likely to have similar pathology in both hips. They have a high likelihood of similarly good outcome after their contralateral hip arthroscopy.     

Editorial Commentary: Expansion of Hip Arthroscopy in Sports Medicine Fellowship Training: The Good,Bad, and Ugly

Orthopaedic sports medicine fellowship experience in hip arthroscopy is increasing rapidly (2.6-fold from 2011 to 2016), although the case numbers vary quite widely (64-fold) depending on the program. Orthopaedic providers are now able to refine diagnoses and refer or render indicated less-invasive hip treatment options, many of which yield outcomes equaling or surpassing those of open equivalents. Patients benefit. Our profession benefits. However, advanced hip arthroscopy procedures are technically challenging, and complications can be significant in inexperienced hands. For those who choose to perform hip arthroscopy after fellowship training, continuing hip arthroscopy education and skill development is essential.     

Editorial Commentary: Hip Radiographic Measurement: It Takes More Than One

The success of hip arthroscopy is based on selecting the right patient. Radiographic measurements are commonly used in the diagnosis of femoroacetabular impingement and other hip pathologies that are treated with hip arthroscopy. Unfortunately, there is not one measurement. For proper patient selection, it is critical to assess for dysplasia and the level of osteoarthritis. The final diagnosis and the decision to proceed with hip arthroscopy should be based on a global evaluation of the joint using different radiographic views and parameters.     

Hip arthroscopy using a limited anterior exposure: an alternative approach for arthroscopic access.

SUMMARY: Hip arthroscopy is a technically difficult procedure to perform. A limited anterior approach to the joint has made hip arthroscopy technically less difficult in our hands and has enabled us to treat a wide range of hip pathology. Five hip arthroscopies were performed using a modified 4-cm Smith-Petersen anterior approach to the hip exposing the joint capsule as manual traction is applied. The arthroscope is then easily introduced making visualization of the hip joint possible. The 5 hip arthroscopies resulted in either removal of loose bodies or debridement of an osteochondral fragment, synovitis, or cartilaginous debris. There were no complications postoperatively. We believe that hip arthroscopy through a limited anterior approach provides an easy and safe alternative method for arthroscopic access to the hip joint. Importantly, there is a decreased risk of neurovascular trauma and iatrogenic damage to the articular cartilage and acetabular labrum when introducing instruments into the hip joint.     

Editorial Commentary: The Child of 2 Mothers: Hip Preservation and Hip Arthroplasty

Two orthopaedic disciplines see the same hip joint from a different angle. The arthroplasty specialist corrects the hip joint osteoarthritis by replacing the hip, while the arthroscopy specialist preserves the joint by correcting the mechanical aberrations. Although both of these approaches are well documented in the literature, some patients who undergo hip preservation surgery will have a subsequent hip replacement. The coexistence of these 2 disciplines, that is, preservation and replacement, could seemingly depend on the effect of a primary preservation surgery on a subsequent replacement. In this commentary, we discuss the effect of hip arthroscopy on a subsequent hip arthroplasty and how these findings lead to harmony between the arthroscopy specialist and the arthroplasty specialist.     

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.     

Arthroscopic removal of intraarticular fragments following fracture dislocation of the hip

We report here a case of posterior dislocation of hip with fracture of posterior lip of acetabulum, with retained fracture fragments after a successful closed reduction. The fractured fragments were removed by arthroscopy of the hip. The technique of hip arthroscopy used in removing the fragments is discussed.