Sports Medicine and Arthroscopy Review

Hip Arthroscopy, Editorial No abstract available

Make the Right Diagnosis: My Pearls for Working Up Hip-related Pain The origin of pain around the hip is commonly more elusive than other joints; often obscured by compensatory disorders. Hip problems tend to be multifactorial and require a multidisciplinary approach in the evaluation. The best strategy is to team with a capable physical therapist to unveil the layers of problems. Ultrasonography and imaging/ultrasound-guided injections can be the most valuable adjunct to the history and physical examination. Plain radiographs are an essential element in the workup. Magnetic resonance imaging can underestimate damage in the joint, but positive findings can sometimes be the normal consequence of age and activity. Magnetic resonance imaging is often as important for what it rules out as much as what it rules in. Computed tomography scans with 3-dimensional reconstructions can be especially helpful in surgical planning but are not used in routine screening, being thoughtful of radiation exposure even with low-dose protocols. Arthroscopic access to the hip is more challenging than other joints, and similarly, unlocking its clinical secrets can be more imposing as well.

Femoroacetabular Impingement and Core Muscle Injury in Athletes: Diagnosis and Algorithms for Success Athletic hip injuries account for a substantial portion of missed time from sports in high-level athletes. For both femoroacetabular impingement (FAI) and core muscles injuries, a thorough history and physical examination are paramount to guide the treatment. While advanced imaging including computed tomography and magnetic resonance imaging are frequently obtained, a wealth of information can be ascertained from standard radiographs alone. For patients with isolated or combined FAI and core muscle injuries (CMIs), the initial treatment is often nonoperative and consists of rest, activity modification, and physical therapy of the hips, core, and trunk. Injections may then aid in both confirming diagnosis and temporary symptom abatement. Arthroscopic procedures for refractory FAI in experienced hands have been shown to be both safe and efficacious. While surgical repair options for CMIs are significantly more variable, long-term studies have demonstrated the rapid resolution of symptoms and high return to play rates. More recently, anatomic and clinical correlations between FAI and CMIs have been identified. Special attention must be paid to elite athletes as the incidence of concurrent FAI with CMI is extremely high yet with significant symptom variability. Predictable return to play in athletes with coexisting symptomatic intra-articular and extra-articular symptomatology is incumbent upon the treatment of both pathologies.

Decision-making in the Borderline Hip Borderline acetabular dysplasia represents a "transitional acetabular coverage" pattern between more classic acetabular dysplasia and normal acetabular coverage. Borderline dysplasia is typically defined as a lateral center-edge angle of 20 to 25 degrees. This definition of borderline dysplasia identifies a relatively narrow range of lateral acetabular coverage patterns, but anterior and posterior coverage patterns are highly variable and require careful assessment radiographically, in addition to other patient factors. Treatment decisions between isolated hip arthroscopy (addressing labral pathology, femoroacetabular impingement bony morphology, and capsular laxity) and periacetabular osteotomy (improving osseous joint stability; often combined with hip arthroscopy) remain challenging because the fundamental mechanical diagnosis (instability vs. femoroacetabular impingement) can be difficult to determine clinically. Treatment with either isolated hip arthroscopy or periacetabular osteotomy (with or without arthroscopy) appears to result in improvements in patient-reported outcomes in many patients, but with up to 40% with suboptimal outcomes. A patient-specific approach to decision-making that includes a comprehensive patient and imaging evaluation is likely required to achieve optimal outcomes.

Capsular Management Techniques and Hip Arthroscopy There has been an increased emphasis on capsular management during hip arthroscopy in the literature in recent years. The capsule plays a significant role in the hip joint stability and studies have demonstrated that capsular closure can restore the biomechanics of the hip back to the native state. Capsular management also affects functional outcomes with capsular repair resulting in better clinical outcomes in some studies. Management of the capsule has evolved in recent years with more surgeons performing routine capsular closure. Management techniques and degree of capsular closure, however, can be quite variable between surgeons. This review will discuss hip capsular anatomy, the importance of the capsule in hip biomechanics, management of the capsule during arthroscopy, and functional outcomes as it relates to the various capsular closure techniques versus leaving the capsulotomy unrepaired.

Surgical Treatment of Labral Tears: Debridement, Repair, and Reconstruction Advances in hip preservation surgery have to lead to increased utilization of hip arthroscopy. With this, there has also been a growth in the understanding of various hip conditions, therefore, leading to an increase in hip conditions amenable to arthroscopic intervention. The acetabular hip labrum has been at the forefront of arthroscopic advances in the hip. The labrum is important for hip stability, provision of the suction seal, and joint proprioception. Given the labrum's central role in hip biomechanics, there is increasing emphasis on labral preservation in the form of debridement and repair. In revision settings, advanced techniques such as labral augmentation and reconstruction may play a role in the management of labral pathology. Appropriate management of the hip labrum at the time of surgery can be an important mediator of the outcome. As such, an understanding of the evolving evidence base and surgical indications and techniques are integral to the treatment and management of labral pathology.

Femoral Version in Hip Arthroscopy: Does it Matter? Femoral version is extremely variable between patients presenting with femoroacetabular impingement (FAI). Careful and routine measurement of femoral anteversion is essential in comprehensive preoperative planning. In general, low degrees of femoral version can lead to anterior impingement (especially on the subspine and distal medial femoral neck). High degrees of anteversion can be seen in the setting of acetabular dysplasia and can lead to anterior hip instability and or posterior impingement. In this article, the authors will discuss the role of routine femoral version management for optimal outcomes after hip arthroscopy for FAI.

Acetabular Rim Disorders/Pincer-type Femoroacetabular Impingement and Hip Arthroscopy Femoroacetabular impingement (FAI) can lead to acetabular impaction, chondral injury, and labral pathology secondary to deformities of the proximal femur (CAM-type FAI), acetabulum (pincer-type FAI), or with combined FAI. While the majority of cases are of the combined type, this paper focuses on acetabular overcoverage/pincer-type deformities. Various pincer subtypes include focal anterior overcoverage, global retroversion, global overcoverage/profunda, protrusio, subspine impingement, and os acetabuli/rim fracture variants. A thorough history and physical examination, plain radiographs, magnetic resonance imaging, 3-dimensional computerized tomography, and diagnostic injections can lead to an accurate assessment of pincer-type variants. Appropriately indicated arthroscopic management techniques and pearls for the various pincer subtypes can lead to improved patient-related outcome measures and a high rate of return to athletic activity for the majority of these patients.

Why Does Hip Arthroscopy Fail? Indications and PEARLS for Revision Success The surgical treatment of femoroacetabular impingement has been shown to have successful early and mid-term clinical outcomes. Despite these favorable clinical outcomes that have been published in the literature, there is a subgroup of patients that present with continued or recurrent symptoms after surgical treatment. Not only has there been an increase in the number of hip arthroscopy procedures, but also there has been a corresponding increase in the number of revision hip arthroscopy and hip preservation surgeries. Previous studies have reported residual deformity to be the most common reason for revision hip arthroscopy. However, chondral, labral, and capsular considerations also are important when addressing patients not only in the primary but also, the revision setting. In this review, we outline the evaluation and treatment of the patient that presents with continued hip and groin pain after undergoing a hip.

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