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: 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—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: 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: 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: 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 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: 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: 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: 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: 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.     

Editorial Commentary: Can We Achieve Personalized Risk Assessment in Hip Arthroscopy?

Gender, age, obesity, osteoarthritis, absence of labral repair, and index procedure performed by a lower volume surgeon were identified as risk factors for reoperation in a statewide study of hip arthroscopy. Although this analysis is helpful for benchmarking expectations for outcome in hip arthroscopy, unaccounted patient variables in the database could significantly complicate and confound the point of care application of the findings.     

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: 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 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: 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: 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: 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: 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: Arthroscopy for Borderline Developmental Dysplasia of the Hip: Selection Determines the Outcomes

Although the literature has presented results that favored arthroscopic procedures in treating borderline developmental dysplasia of the hip (BDDH), it remains controversial whether arthroscopic surgery would be better than periacetabular osteotomy for BDDH. Instead of a debate on the application of arthroscopy, the issue worthy of discussion should be distinguishing suitable BDDH candidates for hip arthroscopy. First, identification of patients with real BDDH is critical for making management choices. Second, it should be distinguished whether the major symptoms result from mechanical lesions or functional hip instability. Third, once hip arthroscopy is suggested for BDDH patients, relative contraindications such as advanced age and osteoarthritis should be taken into consideration, in addition to labral repair and capsular closure or plication intraoperatively. In conclusion, more long-term and high-grade evidence is still demanded to end the debate, but we believe that an individualized management strategy based on an accurate diagnosis and comprehensive assessment will bring optimal outcomes for BDDH patients.