Editorial Commentary: Sexual Function Improves After Hip Arthroscopy for Femoroacetabular Impingement.

Femoroacetabular impingement syndrome can cause pain and difficulty with sexual activity. Arthroscopic treatment of femoroacetabular impingement can improve a patient's sexual health, as seen by improvement in patient-reported outcomes. This correlates with improved quality-of-life scores. Sexual function scores improve for both male and female patients after surgery, but improvement in female patients is greater, most likely because sexual positioning in female patients may involve more flexion, abduction, and rotation than male patients. Reviewing patient-reported outcomes can help provide context for the treating surgeon for discussion both preoperatively and postoperatively.

Editorial Commentary: Preoperative Paralabral Cysts Do Not Have a Detrimental Effect on 2-Year Outcomes After Hip Arthroscopy, but They Can Still Have Predictive Value.

The presence of hip paralabral cysts on magnetic resonance imaging is associated with labral tears and more extensive chondral damage. The 2-year follow-up results of patients with paralabral cysts are equivalent to patients who do not have paralabral cysts. However, since paralabral cysts are associated with more prearthritic hip cartilage damage, surgically addressing these hips sooner could yield better outcomes. Further research is needed to see if performing hip arthroscopy on patients with paralabral cysts more urgently yields better long-term outcomes than delaying surgery.

Editorial Commentary: Hip Range of Motion Is Greater in Women.

Hip range of motion is greater in women. Notably, flexion and internal rotation are significantly greater in women than men. Having a sense of normal variances between female and male range of motion characteristics can help clinicians better identify pathologic findings, which can lead to more prompt treatment for our patients and has implications for injury prevention and activity modification recommendations. A broader understanding of differences between men and women can help with not only treating individual patients but treating large populations of patients.

Two Novel Clinical Tests for the Diagnosis of Hip Labral Tears.

BACKGROUND: There are few well-studied clinical tests for the diagnosis of hip labral tears. As the differential diagnosis for hip pain is broad, accurate clinical examination is important in guiding advanced imaging and identifying patients who may benefit from surgical management. PURPOSE: To determine the diagnostic accuracy of 2 novel clinical tests for the diagnosis of hip labral tears. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 2. METHODS: Clinical examination findings including the Arlington, twist, and flexion-adduction-internal rotation (FADIR)/impingement tests as performed by a fellowship-trained orthopaedic surgeon specializing in hip arthroscopy were obtained from retrospective chart review. The Arlington test ranges the hip from flexion-abduction-external rotation to FADIR while applying subtle internal rotation and external rotation motion. The twist test involves internal rotation and external rotation of the hip while weightbearing. Diagnostic accuracy statistics for each of the tests were calculated using magnetic resonance arthrography as the reference standard. RESULTS: A total of 283 patients were included in the study with a mean age of 40.7 years (range, 13-77 years) and 66.4% were women. The Arlington test was found to have a sensitivity of 0.94 (95% CI, 0.90-0.96), specificity of 0.33 (95% CI, 0.16-0.56), positive predictive value (PPV) of 0.95 (95% CI, 0.92-0.97), and negative predictive value (NPV) of 0.26 (95% CI, 0.13-0.46). The twist test was found to have a sensitivity of 0.68 (95% CI, 0.62-0.73), specificity of 0.72 (95% CI, 0.49-0.88), PPV of 0.97 (95% CI, 0.94-0.99), and NPV of 0.13 (95% CI, 0.08-0.21). The FADIR/impingement test was found to have a sensitivity of 0.43 (95% CI, 0.37-0.49), specificity of 0.56 (95% CI, 0.34-0.75), PPV of 0.93 (95% CI, 0.87-0.97), and NPV of 0.06 (95% CI, 0.03-0.11). The Arlington test was significantly more sensitive than both the twist and FADIR/impingement tests (P < .05), while the twist test was significantly more specific than the Arlington test (P < .05). CONCLUSION: The Arlington test is more sensitive than the traditional FADIR/impingement test, while the twist test is more specific than the FADIR/impingement test in diagnosing hip labral tears in the hands of an experienced orthopaedic surgeon.

Editorial Commentary: To Scope or Not to Scope a Patient With Tönnis Grade 2 Hip Osteoarthritis Remains Ambiguous.

Hip arthroscopy for patients with Tönnis grade 0 or grade 1 hip osteoarthritis and femoroacetabular impingement has been clearly shown to be of benefit, but in patients with definitive joint space narrowing and sclerosis (Tönnis grade 2 or greater hip osteoarthritis), the benefits of hip arthroscopy are ambiguous. There are limited studies on the results of surgery for this combination, and the current research that exists is contradictory. To further confound the question, the Tönnis classification itself shows varying degrees of inter- and intraobserver reliability. One surgeon's Tönnis grade 2 could be another's Tönnis grade 3. In the end, shared decision-making between the surgeon and patients is required when faced with limited research data.

Editorial Commentary: Thermal Pie-Crusting the Hip Capsule Improves Exposure: But Is it Safe?

Thermal pie-crusting of the capsule can increase hip arthroscopy surgical exposure in the peripheral compartment. Recent time-zero biomechanical research suggests that repairing the capsule after pie-crusting yields similar strength and increased stiffness when compared to a T-capsulotomy. However, the risks of thermal damage to the capsule should be weighed against the biomechanical advantages of repairing a pie-crusted capsule versus a T-capsulotomized capsule. In addition, if a surgeon wants to inject an intra-articular orthobiologic such as platelet-rich plasma (PRP), I would not recommend pie-crusting because the full-thickness slits in the capsule could allow the PRP to escape, even after capsular repair. I will still use traction sutures for 100% of my hip arthroscopy procedures. However, in the very rare setting when traction sutures alone yield inadequate exposure, I will perform pie-crusting instead of a T-capsulotomy.

Editorial Commentary: Suture Anchor Fixation Eliminates the Wave Sign and Improves Outcomes for Hip Labrochondral Dysfunction. Do Not Equate Hip Labral Pathology With Shoulder Labral Tears.

During hip arthroscopy, when a wave sign is encountered, it is a sign of labrochondral dysfunction, just like a traditional labral tear. Suture anchor fixation to the labrum can eliminate the wave sign and improve patient outcomes. Readers are urged not to equate hip labral pathology with shoulder labral tears, which have different pathomechanics, and subsequently may have different morphological characteristics.

Editorial Commentary: When Gluteal Strengthening Fails, Hip Femoroacetabular Impingement Correction Is the Ultimate Physical Therapy.

Gluteal strength improvement is positively correlated with improved outcomes following hip arthroscopy femoroacetabular impingement correction. Arthroscopic femoroacetabular impingement surgery in itself also is correlated with postoperative improvement in gluteal strength. A trial of physical therapy or best conservative care can improve gluteal strength; however, oftentimes this is insufficient treatment. Hip arthroscopy can improve pain and function whilst also improving gluteal strength. When this is conveyed to patients, the additional knowledge can help them buy-in to their treatment regimen.

Posterior Femoral Cam Decompression Through an Arthroscopic Anterior Approach With Pre-Bent Hip Burrs.

Hip arthroscopy has been increasingly used to treat labral tears and cam and pincer lesions found in femoroacetabular impingement. Although the classic impingement with cam deformity at the proximal femoral anterolateral quadrant is most common, there has been evidence of cam impingement extension to the anteromedial and posterior quadrants of the proximal femur. Posterior cam decompression carries a theoretical risk of vascular insult and subsequent osteonecrosis, which have led investigators to approach these posterior lesions through an open surgical correction. Recent improvements have led to the development of pre-bent burs that allow for bonier resection flexibility. Here, we report on an arthroscopic posterior cam decompression using the traditional anterior portals and curved hip burs via a figure-of-four positioning technique.

Editorial Commentary: Hip Labral Width Does Not Matter: Now Sit Down and Eat Your Porridge!

Diagnostic hip arthroscopy precedes intervention, and surgeons use a variety of metrics to help devise and refine the treatment plan. Hypertrophic and hypotrophic labra should not be treated differently, and both can be treated successfully with labral repair. Macroscopic and tactile evaluation of labral degeneration and dynamic assessment of the labral suction seal should be used to determine whether a labral tear is best treated by labral repair, labral reconstruction, or labral augmentation.

Editorial Commentary: The Curious Incident of the Bone in the Soft Tissue: Is Heterotopic Ossification After Hip Arthroscopy an Interesting Finding or Is It a Complication?

Heterotopic ossification (HO) following hip arthroscopy is a common finding. Naproxen and celecoxib have both been found to decrease the incidence of HO. Whether this makes a clinical difference to outcomes is unclear at this time. A critical weighing of risks and benefits with regard to HO prophylaxis is warranted. Although the authors will personally continue to use nonsteroidal anti-inflammatory drugs for HO prophylaxis, it is up to the discerning reader to draw her/his own conclusion.

What can we learn from surveys? A systematic review of survey studies addressing femoroacetabular impingement syndrome.

The purpose of this study was to systematically review the methodology, response rate and quality of survey studies related to femoroacetabular impingement (FAI) syndrome. A search was conducted on three databases (PubMed, EMBASE, MEDLINE) for relevant studies from database inception to 27 January 2020. Data extracted included study and survey characteristics, as well as response rates. The quality of the included studies was also assessed using a previously published quality assessment tool. Data were analysed with means, ranges, standard deviations, 95% confidence intervals and bivariate analysis. Eleven studies (13 surveys) were included in this review out of a total of 1608 initial titles found. Surveys were most often administered via the Internet (72%) to orthopaedic surgeons (54%). The mean response rate was 70.4%. The mean quality score was moderate 13.3/24 (SD ±4.3). The criterion that most often scored high was 'clearly defined purpose and objectives' (11/11). The most common survey topic investigated surgeons' knowledge regarding FAI diagnosis and management (n = 7). In addition, bivariate analysis between quality score and response rate showed no significant correlation (Spearman's rho = -0.090, P = 0.85). Overall, survey studies related to FAI syndrome most often use Internet-based methods to administer surveys. The most common target audience is orthopaedic surgeons. The topics of the surveys most often revolve around orthopaedic surgeons' knowledge and opinions relating to the diagnosis and management of FAI syndrome. The response rate is high in patient surveys and lower in larger surgeon surveys. Overall, the studies are of moderate quality.

Editorial Commentary: The Hip Capsule Is No Longer a Problem to Overcome, It Is Part of the Solution.

Hip capsular management is still controversial. Improvements in patient-reported outcomes have been reported with repair of an interportal capsulotomy, which is used for hip access. In addition, a lower rate of conversion to hip replacement after capsular closure has been reported. Central compartment-first arthroscopy violates the capsule at the start of the procedure, so a capsular procedure is being performed at the start of any hip arthroscopy. Even in the absence of hyperlaxity or mild dysplasia, capsular repair should be considered to optimize patient outcomes.

Editorial Commentary: Tönnis Classification-Beauty (or Hip Arthritis) Is Truly in the Eye of the Beholder.

The radiography-based Tönnis classification and magnetic resonance imaging-based International Cartilage Repair Society classification are frequently used to predict articular damage to the hip joint before hip arthroscopy. Despite the ubiquity of these modalities, they both have significant limitations. In particular, the intraobserver reliability and interobserver reliability are less than good. As such, they should be used in conjunction with all other information, most importantly surgical findings, as the basis for treatment decisions.

Editorial Commentary: Treatment of Partial Thickness Undersurface Abductor Tears of the Hip: Like Backwards a Bike Riding.

Partial thickness undersurface abductor tears can be effectively treated with a transtendinous gluteus medius and minimus repair, with decreased pain and improvement in abductor strength. The surgical treatment of this condition runs counter to traditional treatment for "greater trochanteric bursitis," and adoption may be more difficult as a result.

Editorial Commentary: A Steep Learning Curve for Hip Arthroscopy? I Literally Don't Know What This Means Anymore.

Fluoroscopy usage is a common component of hip arthroscopy for femoroacetabular impingement. A surgeon's usage of fluoroscopy (and the subsequent radiation exposure) can decrease over time, as that surgeon gets comfortable with a technique. However, techniques can and usually do change as a surgeon gets increasing experience, and fluoroscopic usage may increase or decrease with different techniques. The term "steep learning curve" should be abandoned, because this term can mean either arduous or easy, depending on context.

The Spin Move: A Reliable and Cost-Effective Gowning Technique for the 21st Century.

Operating room efficiency (ORE) and utilization are considered one of the most crucial components of quality improvement in every hospital. We introduced a new gowning technique that could optimize ORE. The Spin Move quickly and efficiently wraps a surgical gown around the surgeon's body. This saves the operative time expended through the traditional gowning techniques. In the Spin Move, while the surgeon is approaching the scrub nurse, he or she uses the left heel as the fulcrum. The torque, which is generated by twisting the right leg around the left leg, helps the surgeon to close the gown as quickly and safely as possible. From 2003 to 2012, the Spin Move was performed in 1,725 consecutive procedures with no complication. The estimated average time was 5.3 and 7.8 seconds for the Spin Move and traditional gowning, respectively. The estimated time saving for the senior author during this period was 71.875 minutes. Approximately 20,000 orthopaedic surgeons practice in the United States. If this technique had been used, 23,958 hours could have been saved. The money saving could have been $14,374,800.00 (23,958 hours × $600/operating room hour) during the past 10 years. The Spin Move is easy to perform and reproducible. It saves operating room time and increases ORE.

Arthroscopic technique for treatment of combined pathology associated with femoroacetabular impingement syndrome using traction sutures and a minimal capsulotomy.

The use of hip arthroscopy is gaining popularity for diagnostic and therapeutic purposes. With our increasing understanding of hip biomechanics and pathophysiology, our techniques for treatment are evolving as well. The main aim is to preserve the joint and prolong the degenerative process associated with femoroacetabular impingement (FAI). In general, combined pathology is encountered when a diagnosis of FAI is established. In our experience, we have seen large number of patients with a combination of cam and pincer lesions with or without associated labral tears. It is optimal to address all symptomatic pathology with one surgical intervention. The described technique shows the feasibility of dealing with the hip FAI pathology by using traction sutures on the capsule through a 2-portal technique.

Arthroscopy of the nondistractable hip: a novel extracapsular approach.

Adequate traction to achieve hip joint distraction is essential for avoiding iatrogenic injury to the joint during hip arthroscopy. An inability to distract the joint is a relative contraindication for hip arthroscopy. This report describes a novel technique involving an extracapsular approach to gain safe access to a hip joint that fails a trial of traction during positioning for hip arthroscopy. The anterolateral portal is established under fluoroscopic guidance. The arthroscope is positioned on the lateral rim of the acetabulum. A shaver, introduced through a modified anterior portal, is used to facilitate capsular exposure. An arthroscopic capsular incision is made proximal to the lateral acetabular rim and extended anteriorly with a radiofrequency probe. Osteoplasty of the anterolateral acetabular rim is carried out with a burr while protecting the labrum. Distraction of the hip is then possible, allowing safe central-compartment access and subsequent chondrolabral procedures.