Editorial Commentary: Restrictions in Spinal Motion Result in Lower Outcome Scores After Hip Arthroscopy

The critical consideration in determining the efficacy of hip surgery is patient-reported outcomes, specifically the achievement of the clinical threshold. Several studies examined the achievement of the clinical threshold following hip arthroscopy (HA) in the presence of coexisting lumbar spine disease. The condition related to the spine receiving a lot of focus in recent research is the lumbosacral transitional vertebrae (LSTV). However, this condition could be just the tip of the iceberg. To forecast the outcomes of HA, it is far more important to comprehend spinopelvic motion. Since higher-grade LSTV is associated with less lumbar spine flexibility and reduces the ability to antevert acetabulum, it is possible that LSTV severity or grading could be one of the indicators of less effective operation “especially in “hip users”‘ (hip users are defined as patents who are more dependent on on hip motion than spinal motion). In light of this, lower-grade LSTV ought to have a less significant impact on surgical outcomes than higher-grade LSTV.     

Editorial Commentary: A Patient-Specific Approach to Preventing Venous Thromboembolism After Hip Arthroscopy Is Essential

The incidence of hip arthroscopy (HA) has seen a dramatic rise over the past decade, with a bimodal distribution of patient age with peaks at both 18 and 42 years of age. Thus, it is essential to reduce complications, including venous thromboembolism (VTE), given reported incidences as high as 7%. Fortunately, more recent research, perhaps reflecting an evolution resulting in lower HA surgical traction times, has shown a VTE incidence of 0.6%. Perhaps because of such a low rate, recent research has also shown that generally, thromboprophylaxis does not significantly decrease the odds of VTE. The strongest predictors of VTE after HA are oral contraceptive use, prior malignancy, and obesity. Rehabilitation is also an important factor as some patients are ambulatory on postoperative day 1, reducing the VTE risk, whereas others require a few weeks of protected weight bearing, increasing their risk. A patient-specific approach to VTE prevention after HA, rather than a one-size-fits-all approach, is essential.     

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: 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: The First Hip Arthroscopy Is the Best Hip Arthroscopy,Capsular Defect or Not

Hip arthroscopy has evolved significantly over the last 5 to 10 years. With this comes the burden of patients with continued pain after their index procedure. Reasons for the need for revision surgery can be many, including incomplete resection of impingement morphology, unrecognized/unaddressed acetabular dysplasia or hip instability, failure to manage the soft tissue appropriately (i.e., labrum or capsule/ligament), or other unrecognized cause of pain, like femoral retroversion or subspine impingement. Like many other orthopaedic procedures, revision hip arthroscopy with or without a defect in the hip capsule has significantly worse outcomes at 2 years compared with primary hip arthroscopy. This emphasizes the importance of proper diagnosis, well-done surgery, and proper rehabilitation the first time to avoid the need for revision hip surgery in the young adult altogether.     

Editorial Commentary: Postoperative Analgesia After Arthroscopy: A Step Toward the Personalization of Pain Control

Identification of risk factors for prolonged opioid use is imperative as opioid misuse continues to plague society. Recent data suggest that many modifiable and nonmodifiable patient factors may be associated with prolonged opioid use after arthroscopic meniscal surgery. Surgeons and patients share the burden of the opioid epidemic and must collaborate to decrease the overall opioid burden on society. As the number of tools to treat pain and the knowledge of at-risk patients grow, standardized postoperative narcotic regimens to treat a diverse population of patients are no longer acceptable; narcotic regimens must be customized to each patient. To limit opioid use and enhance patient outcomes, it is apparent that the next frontier of postoperative pain control is upon us: the personalization of pain control.     

Editorial Commentary: Hip Labral Reconstruction: A Necessary Skill for Hip Arthroscopy Surgeons

The surgical treatment of labral deficiency has generated a tremendous amount of discussion and controversy among hip arthroscopists. The surgical reconstruction of the labrum has been viewed as the natural next step, after debridement and repair, in the advancement of our ability to treat patients with hip labral pathology. However, the indications for labral replacement and the profile of patients who would benefit from this complex intervention are still under debate. Every hip arthroscopist must have the technical ability to perform reconstruction when indicated. Repair or debridement does not always achieve best patient outcome.     

Editorial Commentary: The Truth about Peripheral Nerve Blocks and Hip Arthroscopy

Peripheral nerve blocks targeting the fascia iliaca compartment have been used in attempts to improve postoperative pain after hip arthroscopy surgery. Recent level I evidence from randomized controlled trials have revealed injection of local anesthetic into the fascia iliaca compartment to be no better than sham injection for postoperative pain control, while contributing to decreased patient quadriceps strength and increased fall risk after surgery. The fascia iliaca compartment block is also inferior to local anesthetic injection at the surgery site for pain control. Results of these high-level studies show that routine preoperative use of the fascia iliaca compartment block is not recommended for hip arthroscopy.     

Editorial Commentary: Hip Arthroscopy Pump Pressure Must Be Managed and Monitored

Fluid pump management is essential for successful hip arthroscopy. Low pressures can lead to poor visualization. High pressures can lead to fluid extravasation and complications. Fluid extravasation during hip arthroscopy can lead to intra-abdominal compartment syndrome, which can be life-threatening. Risk factors for extravasation included higher pump pressures and iliopsoas tenotomy. By accurately measuring pump pressures, minimizing the necessary pressure, avoiding excessive capsulotomies, performing iliopsoas tenotomy only if needed and performing it at the end of the operation, and monitoring the patient for abdominal distention and hypothermia, complications can be minimized.     

Editorial Commentary: The Optimal Nerve Block for Hip Arthroscopy Is Undetermined

The optimal nerve block to help reduce pain after hip arthroscopy is undetermined. The fascia iliaca block was en vogue but may result in weakness, neuropathy, and equivocal pain outcomes. Other options include blocks to the femoral nerve, the lumbar plexus, the quadratus lumborum, and, more recently, the pericapsular nerve group block (PENG), in which ultrasound guidance allows injection under the iliopsoas muscle to affect the accessory obturator nerve and the articular branches of the femoral nerve. PENG block should not result in weakness, but weakness has been reported after PENG block for total hip arthroplasty, and falls could be a risk and a concern. The arthroplasty literature also suggests the PENG block adds little benefit to intra-articular injection beyond the recovery room and is comparable with a fascia iliac block. Perhaps the PENG block could show benefit in select cases such as for severe postoperative pain or in patients with anticipated pain control challenges. Until an ideal block for hip arthroscopy is determined, a patient tailored approach is indicated.     

Editorial Commentary: Quantifying Patient Satisfaction After Hip Arthroscopy: I Cannot Deactivate Until You Are Satisfied With Your Care

The evolution of hip-preservation research is now streamlining toward evaluating our results as they relate to minimal clinically important difference, patient acceptable symptomatic state and substantial clinical benefit and less to P value-only significance. The keystone to successful hip-preservation procedures lies in proper patient selection, expert surgical execution, following results, and measuring satisfaction over time. Having a truly objective measure for establishing patient satisfaction is paramount to guiding surgical success.     

Editorial Commentary: Arthroscopy of the Hip (Not the Abdomen!)

Hip arthroscopists and the surgical team should be aware of the potential complication of intra-abdominal fluid extravasation (IAFE). Fluid extravasation may be relatively common. Fortunately, symptomatic IAFE remains rare but can be serious. Increased peak inspiratory pressure (PIP) should be a parameter that we follow and discuss with our anesthesia colleagues. This would be an excellent point to bring up during the mandatory preoperative time out. Increased PIP or hemodynamic instability should warrant a consideration of IAFE.     

Total Hip Arthroplasty Improves Pain and Function but Not Physical Activity

BackgroundPeople with hip osteoarthritis are likely to limit physical activity (PA) engagement due to pain and lack of function. Total hip arthroplasty (THA) reduces pain and improves function, potentially allowing increased PA. PA of THA patients was quantified to 12 months postoperation. The hypothesis was that postoperatively levels of PA would increase.MethodsPA of 30 THA patients (67 ± 7 years) was objectively measured preoperatively and 3 and 12 months postoperation. Harris Hip Score (HHS), Oxford Hip Score (OHS), and 6-minute walk test (6MWT) were recorded. Mixed linear modelling was used to examine relationships of outcomes with time, baseline body mass index (BMI), age, gender, and baseline HHS.ResultsTime was not a significant factor in predicting volume measures of PA, including sit-to-stand transitions, upright time, and steps. Notably, baseline BMI was a significant predictor of upright time, steps, largest number of steps in an upright bout, HHS, and 6MWT. Baseline HHS helped predict longest upright bout, cadence of walking bouts longer than 60 seconds, and OHS. The significant effect of participant as a random intercept in the model for PA outcomes suggested habituation from presurgery to postsurgery.ConclusionVolume measures of PA did not change from presurgery to 12 months postsurgery despite improvement in HHS, OHS, and 6MWT. Baseline BMI was a more important predictor of upright activity and stepping than time. Preoperative and postoperative PA promotion could be used to modify apparently habitual low levels of PA to enable full health benefits of THA to be gained.     

Editorial Commentary: Outcome After Ipsilateral Hip Arthroscopy Predicts Outcomes on the Contralateral Side,Regardless of Time Between Surgeries

Surgical predictability is a multifactorial methodology of coordinated actions backed by clinical expertise and historical tracking. Recent research shows outcome after ipsilateral hip arthroscopy predicts outcomes on the contralateral side, regardless of time between surgeries. This is based on research by experienced surgeons who have achieved reproducibility, predictability, and consistency of their outcomes. To patients at time of scheduling, this translates to, "Trust us, we know what we’re doing." This research may not be generalizable to low volume or inexperienced hip arthroscopists.     

Editorial Commentary: Obesity Is Associated With Lower Hip Function Pre- and Postoperatively and Increased Time to Patient Acceptable Symptom State After Hip Arthroscopy

In 2015, worldwide, there were more than 1.9 billion adults classified as having overweight (body mass index [BMI] >25), with 600 million of these individuals meeting the definition of obesity (BMI >30). Hip arthroscopy in patients with obesity can lead to improve outcomes, albeit with lower absolute levels of patient-reported outcome scores and with increased risk of complications and conversion rates to total hip arthroplasty when compared with their counterparts without obesity. Importantly, a significantly longer time to patient acceptable symptoms state achievement is seen for patients with class I obese than patients with normal BMI. Unfortunately, the hip is quite susceptible to the effects of obesity, with greater acetabular depth/deformity, reduced femoral head cartilage, greater forces experienced with ambulation, and a predisposition to femoroacetabular impingement syndrome. Thus, almost 42% of patients operated on in North America for femoroacetabular impingement syndrome are classified as having overweight or obesity. This does not need to deter from the consideration of arthroscopic hip surgery in the population with obesity; rather, it supports a discussion between surgeon and patient on expectations and timeline for improvement.     

Editorial Commentary: Hip Arthroscopy Wins the National Basketball Association Slam Dunk Contest!

Hip arthroscopy has proved its efficacy and value in the management of femoroacetabular impingement syndrome in recreational and professional athletes. However, needs, expectations, and economic burden are remarkable and astonishingly different within the elite sport world. When considering hip arthroscopy to address a femoroacetabular impingement condition, 3 big questions are asked by every athlete and must be answered: (1) Can I play again? (2) Will I play at the same level? (3) When can I return to sport? Regarding the National Basketball Association, approximately 88% of athletes return to play at the same level in about 6 months.     

Editorial Commentary: Hip Arthroscopy With Concomitant Periacetabular Osteotomy: Teamwork Makes This Dream Work

Arthroscopy provides a powerful tool to successfully treat intra-articular hip pathology secondary to dysplasia while improving the bony coverage/alignment with periacetabular osteotomy; a concept no different than high tibial osteotomy. Through a specialized team approach, all relevant pathology can be addressed and successful outcomes achieved.     

Editorial Commentary: Iliopsoas Tenotomy for Pain After Total Hip: A Great Operation IF the Diagnosis Is Right

Iliopsoas tendon pain can be a frustrating condition for both patients and surgeons after total hip arthroplasty. It is difficult to diagnose definitively, as there is no imaging modality that offers reliable information and there are numerous causes of persistent groin pain in this patient population. The pain can ruin the results of an otherwise well-functioning total hip arthroplasty. Patients who respond best to arthroscopic iliopsoas tenotomy are those with isolated pain with hip flexion activities and reproducible pain with resisted hip flexion on examination or other provocative iliopsoas maneuvers. Patients with these symptoms in addition to more generalized pain findings (pain with weight-bearing, pain at night, pain with passive range of motion) tend not to respond as favorably to isolated iliopsoas tenotomy. In addition, optimal treatment for refractory cases has been controversial historically, as both acetabular component revision and iliopsoas tendon lengthening have been advocated. With the ever-increasing popularity of hip arthroscopy and recent clinical outcome reports, arthroscopic (or endoscopic) iliopsoas tenotomy has proven to be a very safe and effective treatment option for these patients, with one caveat: the diagnosis must be correct.