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: 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.     

Editorial Commentary: Hip Capsule: To Repair or Not?

Arthroscopic hip capsular repair is an area of intense interest. Basic science studies suggest that adverse changes in capsular stability/restraint may occur with capsulotomy and capsulectomy, that repair may ameliorate these changes, and, most recently, that the repaired capsule usually heals. Clinical studies suggest that in some conditions, most notably mild dysplasia, capsular repair or plication may improve short-term outcomes, but in general, the role of capsular closure is less clear. At present, perhaps a selective approach is merited, with capsular closure performed in patients with dysplasia, focal or generalized hyperlaxity, and/or increased femoral anteversion. The comparative outcomes from smaller, more vertically oriented capsulotomies with less violation of the iliofemoral ligament deserve investigation.     

Editorial Commentary: Optimizing Surgical Management of Ankle Fractures: Is Arthroscopy the Answer?

The surgical management of ankle fractures can be an unforgiving endeavor. Subtle malreductions in fracture fragments lead to significant deviations in joint reactive forces and, consequently, accelerated arthritis. The diagnosis of associated ligamentous pathology, such as deltoid and syndesmotic injuries, is often difficult and ideal surgical management is debated. Ankle fractures that are seemingly optimally managed using traditional surgical techniques may remain persistently painful and function poorly—a scenario that begs the question, was there more to the injury than met the eye (or radiographs)? Here, unrecognized concomitant intra-articular injuries and subtle surgical malreductions have been implicated. In my practice, concurrent ankle arthroscopy at the time of definitive acute ankle fracture reduction and fixation results in improved accuracy of reduction, evaluation and management of concomitant syndesmotic and ligamentous injuries, assessment and treatment of occult intra-articular injuries, options for less-invasive fixation techniques through arthroscopic reduction, and a means to provide prognostic patient information. I typically reserve its use for fracture patterns that have been more closely associated with intra-articular injuries: high-energy mechanism injuries, Weber B and C fibula fractures, and those with a high likelihood of syndesmotic disruption based on preoperative imaging. Despite these intuitive advantages, concurrent ankle arthroscopy for acute fracture fixation is not routinely performed by most orthopedic surgeons, and a relative dearth of literature regarding its use and clinical impact remains.     

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 in Hip Dysplasia: Just Because You Are Doing It,Should You?

As surgeons advance the field of hip arthroscopy and perform more hip arthroscopy in patients with hip dysplasia and associated femoroacetabular impingement, we need to publish more outcome studies to determine this procedure's success and safety in this specific group of patients.     

Editorial Commentary: Safe Innovation? Arthroscopy After Traumatic Hip Dislocation

Hip arthroscopy can be helpful relative to conventional imaging when diagnosing (and treating) intra-articular injuries after a hip dislocation, but more evidence is required before adopting this approach diagnostic and therapeutic strategy.     

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: Low-Dose Hip Computed Tomography Sharpens the Saw for Hip Preservation: Can It Cut the Tree?

Computed tomography scans provide excellent visualization of complex hip deformities and assist in the diagnosis and surgical planning of hip preservation surgery. The dose of harmful ionizing radiation can be reduced while preserving reasonable image quality. Low-dose hip computed tomography can be used successfully for preoperative planning. Readers should consider strategies to reduce the radiation dose from computed tomography scans and consider magnetic resonance imaging arthrograms for assessment of cartilage and labral status before hip preservation surgery.     

Editorial Commentary: Total Hip Arthroplasty After Hip Arthroscopy—Solution for the Failed Arthroscopy or a Matter of Pushing the Envelope and Questionable Indications

With the inevitable explosion of arthroscopic hip procedures being performed, the less frequent indications and failures are becoming prevalent enough to analyze. As with any procedure, failures occur and solutions are sought after. “Total hip arthroplasty after prior hip arthroscopy” is a statement that brings to mind several questions and comments. Yes, it is important to evaluate the impact of a prior arthroscopy on eventual total hip arthroplasty outcomes and complication rates. The bigger question when the arthroplasty is performed less than 2 years after hip arthroscopy, however, is “How did we get here?” The pivotal issue at hand might be one of pushing surgical indications a bit too forcefully on multiple fronts. It might be time to return to “Indications 101” to minimize an exponential increase regarding this particular topic with this particular failure timeline.     

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: 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.     

Editorial Commentary: Readmission Rate After Hip Arthroscopy: Is There a Cause for Concern?

Readmission after hip arthroscopic surgery is an undesired and unusual event. The causes may range from wound-related issues, deep infection, increasing pain, complications of surgery, to medical events. It adds to the economic burden of the procedure and causes unnecessary anguish to the patients and indeed clinicians. It is also one of the less-studied areas of hip arthroscopic surgery because of its rarity. There would be benefit in being able to identify the risk factors of readmission such that pre-emptive measures can be put in place to prevent or indeed counsel the patients before the surgery. In certain cases, readmission may remain an unpreventable event. In our experience, the readmission rate after hip arthroscopy is 0.5%, whereas patients with elevated body mass index are at greater risk.     

Editorial Commentary: Rehabilitation After Hip Arthroscopy—Bear in Mind the Bearing of Weight

Hip arthroscopy is the surgical treatment of choice for the treatment of femoroacetabular impingement syndrome and hip labral tears. Current guidelines on postoperative rehabilitation protocols are based on expert opinion, and evidence-based protocols are scarce. Previously, a non–weight-bearing protocol for several weeks after surgery was thought to prevent axial-load damage to the newly repaired labrum. However, there is a trend toward using immediate weight bearing as tolerated for early joint mobilization and pressurization. Strict weight-bearing restrictions may not be as necessary as once thought. We recommend that the first phase of rehabilitation prioritize joint protection to prevent joint inflammation and tissue irritation with a gradual increase in mobility exercises to restore range of motion. However, rehabilitation protocols should be tailored to address specific surgical findings, procedures, patient characteristics, and athletic goals. It is wise to be more conservative in older patients with poor bone quality. Bearing in mind this caveat, weight-bearing restrictions after hip arthroscopy may not improve outcomes and instead may have the negative effect of preventing patients from re-establishing a normal gait pattern.     

Editorial Commentary: Pain After Hip Arthroscopy—Are We Truly Addressing the Problem?

Pain after hip arthroscopy is a significant and challenging issue as is evidenced by the number of publications on this subject. Various analgesic strategies to circumvent this issue have been tried, with variable results. The central problem is that pain experienced by patients after hip arthroscopy is multifactorial in origin. Regarding local injection, an anatomic approach to the nerve supply to the hip with an effective pain relief strategy should take this into consideration and focus on using drugs with a low risk of complications and infiltration techniques that do not cause an unnecessary delay in rehabilitation and discharge of the patient. Furthermore, addressing traction time, surgical technique, and fluid extravasation and applying an individualized approach, keeping the patient’s personality and profile in mind, will ensure adequate analgesia after arthroscopic intervention.     

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: Hip Arthroscopy for Femoroacetabular Impingement: Outcomes May Be Depressing

Hip arthroscopy can be an extremely effective treatment for femoroacetabular impingement syndrome. As with any surgery, our clinical outcomes are directly related to proper patient selection. As orthopaedic surgeons, we often focus on the functional and painful history complaints, the physical examination maneuvers, and radiographic studies to determine whether patients will respond well to surgical treatment. However, we oftentimes overlook the overall well-being of our patients and forget how psychosocial factors may limit surgical outcomes. Patients need to be counseled about the importance of medically maximizing their overall well-being and addressing any underlying stress, anxiety, or depression. Although psychosocial factors are not a contraindication to surgery, they certainly play a major role in our ultimate goal of improving our patients' quality of life and function.     

Editorial Commentary: Hip Arthroscopy in the Professional Athlete…Back in the Game

With improved outcomes and expanding indications, the rate of hip arthroscopy for treatment of numerous pathologies has increased. There is significant interest from patients and providers alike regarding return to meaningful play after surgical intervention, particularly for the professional athlete. Although each athlete and each sport have unique obstacles, the literature suggests hip arthroscopy has a high success rate and allows for elite athletes to return to play without significant differences in postoperative performance scores.     

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: Intra-articular Injection for Osteoarthritis—Is It Hip or Not?

Intra-articular injections are commonly used in the treatment algorithm for osteoarthritis of the hip. A number of different adjuvants can be used, such as corticosteroids, hyaluronic acid, and platelet-rich plasma, but there is no consensus regarding indications for or anticipated outcomes of each of these interventions. Recent data suggest that corticosteroids provide the best relief in the short term whereas platelet-rich plasma may be more beneficial in the mid term, but the results are variable. Ultimately, more rigorous studies are needed to evaluate these adjuvants, in particular biologics, while remaining fastidious with our indications for injection therapy.