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Editorial Commentary: Revision Hip Surgery After Arthroscopy—What Went Wrong? Are There Second Chances?

      Abstract

      Hip arthroscopy allows minimally invasive treatment of femoroacetabular impingement (FAI) with labral tears. Over the last 2 decades, the indications and techniques for treatment of FAI have evolved, and complex pathology can now be treated arthroscopically. Short- and medium-term patient-reported outcomes demonstrate the reliability of hip arthroscopy for treatment of FAI, although a subset of patients fail to achieve desired results and require revision surgery. The indications for revision surgery after a primary hip arthroscopy are not well described in a large series, and most reviews focus on revision arthroscopy at the exclusion of open surgery (notably periacetabular osteotomy and total hip arthroplasty). Furthermore, patient-reported outcomes after these revision procedures have not been recently summarized.
      The field of hip arthroscopy for the treatment of femoroacetabular impingement (FAI) underwent rapid growth over the last decade,
      • Bonazza N.A.
      • Homcha B.
      • Liu G.
      • Leslie D.L.
      • Dhawan A.
      Surgical trends in arthroscopic hip surgery using a large national database.
      ,
      • Cvetanovich G.L.
      • Chalmers P.N.
      • Levy D.M.
      • et al.
      Hip arthroscopy surgical volume trends and 30-day postoperative complications.
      and with increased primary procedures, a proportional increase in revision procedures can be expected. The study “Indications and Outcomes of Secondary Hip Procedures After Failed Hip Arthroscopy: A Systematic Review” by Shapira, Kyin, Go, Rosinsky, Maldonado, Lall, and Domb sought to determine indications for subsequent procedures (revision arthroscopy, secondary periacetabular osteotomy [PAO], and secondary total hip arthroplasty [THA]) after “failed hip arthroscopy” as well as summarize patient-reported outcomes.
      • Shapira J.
      • Kyin C.
      • Go C.
      • et al.
      Indications and outcomes of secondary hip procedures after failed hip arthroscopy. A systematic review.
      Proper diagnosis before the primary procedure enables appropriate preoperative planning and helps to ensure expected outcomes. Patient history and examination provide the foundation for the evaluation of patients with FAI.
      • Frangiamore S.
      • Mannava S.
      • Geeslin A.G.
      • Chahla J.
      • Cinque M.E.
      • Philippon M.J.
      Comprehensive clinical evaluation of femoroacetabular impingement: Part 1, physical examination.
      Plain radiographs are invaluable in the assessment of bony anatomy.
      • Mannava S.
      • Geeslin A.G.
      • Frangiamore S.J.
      • et al.
      Comprehensive clinical evaluation of femoroacetabular impingement: Part 2, plain radiography.
      Axial imaging, usually with magnetic resonance imaging, allows multiplanar assessment of anatomy and enables evaluation of soft tissue, including the labrum, cartilage, and tendons.
      • Geeslin A.G.
      • Geeslin M.G.
      • Chahla J.
      • Mannava S.
      • Frangiamore S.
      • Philippon M.J.
      Comprehensive clinical evaluation of femoroacetabular impingement: Part 3, magnetic resonance imaging.
      Together, this allows correlation of symptoms and examination findings to soft-tissue pathology and quantitative bony morphology.
      Once a correct diagnosis is established, preoperative planning is undertaken. It is important to note that hip arthroscopy is relatively immature compared with other disciplines of orthopaedic sports medicine, and debate remains in virtually all areas. Evolution is anticipated with regard to planning and execution, specifically including systematic correction of cam morphology (now available intraoperatively through proprietary software), capsular-management strategies, management of acetabular and femoral version abnormalities, threshold for intervention in patients with chondral pathology, indications for labral treatment (whether repair, reconstruction, or debridement), and optimization of algorithms in patients with dysplastic and borderline dysplastic acetabular morphology. Preoperative planning for a primary procedure is critical and, as the authors establish, careful planning is arguably of greater importance in a subsequent procedure.
      The authors use the term “failed hip arthroscopy” to refer to patients who underwent a subsequent procedure. Although imprecise, this is a reasonable description, as many consider the need for a subsequent procedure as evidence that the primary procedure failed to produce a desired outcome. An important distinction that is challenging to address in this study type is whether the “failure” was in planning or execution. Rather than categorically defining failure as need for subsequent surgery, an alternative method to analyze outcomes is through the use of clinically meaningful measures such as patient-acceptable symptomatic state and minimal clinical important difference, as these may be a more sensitive tool to evaluate the success of hip arthroscopy procedures.
      • Beck E.C.
      • Nwachukwu B.U.
      • Kunze K.N.
      • Chahla J.
      • Nho S.J.
      How can we define clinically important improvement in pain scores after hip arthroscopy for femoroacetabular impingement syndrome? Minimum 2-year follow-up study.
      Not surprisingly, the indications for subsequent surgery appear identical to the most common indications for primary hip surgery. Shapira et al.
      • Shapira J.
      • Kyin C.
      • Go C.
      • et al.
      Indications and outcomes of secondary hip procedures after failed hip arthroscopy. A systematic review.
      reported that labral tears and FAI were the most common indications for revision arthroscopy. Furthermore, secondary PAO was most commonly performed to address acetabular dysplasia, and arthritis was the most common indication for secondary THA. Evaluation of outcomes revealed improvement after revision arthroscopy, although this was to a lesser extent than a control group undergoing primary hip arthroscopy. The systematic review was unable to conclusively state whether patients who underwent secondary PAO or THA achieved comparable outcomes with control groups undergoing primary PAO or THA.
      The authors are to be commended for performing a well-executed systematic review that broadens our understanding of this patient population. However, inherent to the limitations of systematic reviews, readers are unable to determine whether the subsequent procedures were required due to poor primary hip arthroscopy indications (e.g., dysplastic hip with lateral center-edge angle of 15°, arthritic hip with bipolar grade IV chondrosis and osteophyte formation), incorrect execution (e.g., inappropriate femoral resection, labral debridement rather than repair of a repairable tear, over-resection of a pincer lesion, iatrogenic damage), or borderline indications in a challenging patient group (e.g., young patient with borderline remaining joint space and advanced chondrosis on magnetic resonance imaging, borderline dysplasia in a patient with ligamentous laxity). An alternative scenario is natural progression of joint degeneration despite an appropriately indicated patient with a properly executed procedure.
      Likely the most important question for patients, surgeons, and payers alike is whether primary hip arthroscopy performed for the correct indication with the proper technique leads to a successful outcome with a low risk of a “failed” procedure. An important follow-up question is whether reliable “bail-out” options are available for patients with an unsuccessful primary procedure. The results reported by Shapira et al.
      • Shapira J.
      • Kyin C.
      • Go C.
      • et al.
      Indications and outcomes of secondary hip procedures after failed hip arthroscopy. A systematic review.
      are reassuring and indicate that a reasonable outcome can still be achieved in a revision procedure.

      Supplementary Data

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