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

      Abstract

      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.
      Hip arthroscopy for borderline developmental dysplasia of the hip (BDDH) has been reported to achieve satisfactory outcomes within follow-up periods of 2 to 5 years.
      • Beck E.C.
      • Nwachukwu B.U.
      • Chahla J.
      • et al.
      Patients with borderline hip dysplasia achieve clinically significant outcome after arthroscopic femoroacetabular impingement surgery: A case-control study with minimum 2-year follow-up.
      • Byrd J.W.
      • Jones K.S.
      Hip arthroscopy in the presence of dysplasia.
      • Chaharbakhshi E.O.
      • Hartigan D.E.
      • Perets I.
      • Domb B.G.
      Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
      • Chaharbakhshi E.O.
      • Perets I.
      • Ashberg L.
      • Mu B.
      • Lenkeit C.
      • Domb B.G.
      Do ligamentum teres tears portend inferior outcomes in patients with borderline dysplasia undergoing hip arthroscopic surgery? a match-controlled study with a minimum 2-year follow-up.
      • Chandrasekaran S.
      • Darwish N.
      • Martin T.J.
      • Suarez-Ahedo C.
      • Lodhia P.
      • Domb B.G.
      Arthroscopic capsular plication and labral seal restoration in borderline hip dysplasia: 2-Year clinical outcomes in 55 cases.
      • Christensen J.C.
      • Marland J.D.
      • Miller C.J.
      • Horton B.S.
      • Whiting D.R.
      • West H.S.
      Trajectory of clinical outcomes following hip arthroscopy in female subgroup populations.
      • Cvetanovich G.L.
      • Levy D.M.
      • Weber A.E.
      • et al.
      Do patients with borderline dysplasia have inferior outcomes after hip arthroscopic surgery for femoroacetabular impingement compared with patients with normal acetabular coverage?.
      • Domb B.G.
      • Chaharbakhshi E.O.
      • Perets I.
      • Yuen L.C.
      • Walsh J.P.
      • Ashberg L.
      Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
      • Domb B.G.
      • Stake C.E.
      • Botser I.B.
      • Jackson T.J.
      Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: A prospective matched-pair study with average 2-year follow-up.
      • Evans P.T.
      • Redmond J.M.
      • Hammarstedt J.E.
      • Liu Y.
      • Chaharbakhshi E.O.
      • Domb B.G.
      Arthroscopic treatment of hip pain in adolescent patients with borderline dysplasia of the hip: Minimum 2-year follow-up.
      • Fukui K.
      • Briggs K.K.
      • Trindade C.A.
      • Philippon M.J.
      Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia.
      • Garabekyan T.
      • Ashwell Z.
      • Chadayammuri V.
      • et al.
      Lateral acetabular coverage predicts the size of the hip labrum.
      • Hatakeyama A.
      • Utsunomiya H.
      • Nishikino S.
      • et al.
      Predictors of poor clinical outcome after arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of borderline hip dysplasia.
      • Ishøi L.
      • Thorborg K.
      • Kraemer O.
      • Lund B.
      • Mygind-Klavsen B.
      • Hölmich P.
      Demographic and radiographic factors associated with intra-articular hip cartilage injury: A cross-sectional study of 1511 hip arthroscopy procedures.
      • Kalisvaart M.M.
      • Safran M.R.
      Hip instability treated with arthroscopic capsular plication.
      • Kalore N.V.
      • Jiranek W.A.
      Save the torn labrum in hips with borderline acetabular coverage.
      • Kaya M.
      • Suzuki T.
      • Emori M.
      • Yamashita T.
      Hip morphology influences the pattern of articular cartilage damage.
      • Maldonado D.R.
      • Perets I.
      • Mu B.H.
      • et al.
      Arthroscopic capsular plication in patients with labral tears and borderline dysplasia of the hip: Analysis of risk factors for failure.
      • Matsuda D.K.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Arthroscopic outcomes as a function of acetabular coverage from a large hip arthroscopy study group.
      • Nawabi D.H.
      • Degen R.M.
      • Fields K.G.
      • et al.
      Outcomes after arthroscopic treatment of femoroacetabular impingement for patients with borderline hip dysplasia.
      • Ohnishi Y.
      • Suzuki H.
      • Nakashima H.
      • et al.
      Radiologic correlation between the ischiofemoral space and morphologic characteristics of the hip in hips with symptoms of dysplasia.
      • Wyatt M.
      • Weidner J.
      • Pfluger D.
      • Beck M.
      The femoro-epiphyseal acetabular roof (FEAR) index: A new measurement associated with instability in borderline hip dysplasia?.
      • Yoon S.J.
      • Lee S.H.
      • Jang S.W.
      • Jo S.
      Hip arthroscopy of a painful hip with borderline dysplasia.
      Our previous study concluded that overall satisfactory improvement regarding patient-reported outcomes was achieved after isolated hip arthroscopy for BDDH,
      • Ding Z.
      • Sun Y.
      • Liu S.
      • Chen J.
      Hip arthroscopic surgery in borderline developmental dysplastic hips: A systematic review.
      and the conclusion is corroborated in the current systematic review entitled “Arthroscopy and Borderline Developmental Dysplasia of the Hip: A Systematic Review” by Kuroda, Saito, Kumar, Malviya, and Khanduja.
      • Kuroda Y.
      • Saito M.
      • Kumar K.H.S.
      • Malviya A.
      • Khanduja V.
      Arthroscopy and borderline developmental dysplasia of the hip: A systematic review.
      However, it still remains controversial whether hip arthroscopy is a better option than periacetabular osteotomy (PAO) for BDDH.
      • Byrd J.W.
      • Jones K.S.
      Hip arthroscopy in the presence of dysplasia.
      ,
      • Ding Z.
      • Sun Y.
      • Liu S.
      • Chen J.
      Hip arthroscopic surgery in borderline developmental dysplastic hips: A systematic review.
      ,
      • Parvizi J.
      • Bican O.
      • Bender B.
      • et al.
      Arthroscopy for labral tears in patients with developmental dysplasia of the hip: A cautionary note.
      Surgeons opposing arthroscopy for BDDH have argued that it only addresses the soft tissues, that is, the secondary stabilizers of the hip, not solving the biomechanical problems associated with the abnormal osseous geometry.
      • Parvizi J.
      • Bican O.
      • Bender B.
      • et al.
      Arthroscopy for labral tears in patients with developmental dysplasia of the hip: A cautionary note.
      • Wyatt M.C.
      • Beck M.
      The management of the painful borderline dysplastic hip.
      • Ross J.R.
      • Zaltz I.
      • Nepple J.J.
      • Schoenecker P.L.
      • Clohisy J.C.
      Arthroscopic disease classification and interventions as an adjunct in the treatment of acetabular dysplasia.
      We have to admit that most published studies in the literature about hip arthroscopy in patients with BDDH had low-level evidence and only reported short-term outcomes. Up to now, neither long-term follow-up studies nor randomized controlled trials comparing arthroscopy and PAO among BDDH patients have been available. It seems that this debate will go on in the near future. We advocate pausing the debate comparing PAO and arthroscopy in treating BDDH and instead turning to defining the subgroup of BDDH patients who can achieve optimal outcomes after arthroscopic procedures. In other words, selection of suitable BDDH candidates for arthroscopy will determine the outcomes on a great scale.
      First, patients with real BDDH should be distinguished and selected. Normally, BDDH is defined by a lateral center-edge angle (LCEA) between 20° and 25°
      • Beck E.C.
      • Nwachukwu B.U.
      • Chahla J.
      • et al.
      Patients with borderline hip dysplasia achieve clinically significant outcome after arthroscopic femoroacetabular impingement surgery: A case-control study with minimum 2-year follow-up.
      ,
      • Byrd J.W.
      • Jones K.S.
      Hip arthroscopy in the presence of dysplasia.
      ,
      • Evans P.T.
      • Redmond J.M.
      • Hammarstedt J.E.
      • Liu Y.
      • Chaharbakhshi E.O.
      • Domb B.G.
      Arthroscopic treatment of hip pain in adolescent patients with borderline dysplasia of the hip: Minimum 2-year follow-up.
      • Fukui K.
      • Briggs K.K.
      • Trindade C.A.
      • Philippon M.J.
      Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia.
      • Garabekyan T.
      • Ashwell Z.
      • Chadayammuri V.
      • et al.
      Lateral acetabular coverage predicts the size of the hip labrum.
      • Hatakeyama A.
      • Utsunomiya H.
      • Nishikino S.
      • et al.
      Predictors of poor clinical outcome after arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of borderline hip dysplasia.
      ,
      • Kaya M.
      • Suzuki T.
      • Emori M.
      • Yamashita T.
      Hip morphology influences the pattern of articular cartilage damage.
      ,
      • Ohnishi Y.
      • Suzuki H.
      • Nakashima H.
      • et al.
      Radiologic correlation between the ischiofemoral space and morphologic characteristics of the hip in hips with symptoms of dysplasia.
      ,
      • Yoon S.J.
      • Lee S.H.
      • Jang S.W.
      • Jo S.
      Hip arthroscopy of a painful hip with borderline dysplasia.
      ,
      • Ashwell Z.R.
      • Flug J.
      • Chadayammuri V.
      • Pascual-Garrido C.
      • Garabekyan T.
      • Mei-Dan O.
      Lateral acetabular coverage as a predictor of femoroacetabular cartilage thickness.
      • Bolia I.K.
      • Briggs K.K.
      • Locks R.
      • Chahla J.
      • Utsunomiya H.
      • Philippon M.J.
      Prevalence of high-grade cartilage defects in patients with borderline dysplasia with femoroacetabular impingement: A comparative cohort study.
      • Kobayashi N.
      • Inaba Y.
      • Kubota S.
      • et al.
      The distribution of impingement region in cam-type femoroacetabular impingement and borderline dysplasia of the hip with or without cam deformity: A computer simulation study.
      • Kraeutler M.J.
      • Goodrich J.A.
      • Ashwell Z.R.
      • Garabekyan T.
      • Jesse M.K.
      • Mei-Dan O.
      Combined lateral osseolabral coverage is normal in hips with acetabular dysplasia.
      or between 18° and 25° according to some modifications.
      • Chaharbakhshi E.O.
      • Hartigan D.E.
      • Perets I.
      • Domb B.G.
      Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
      • Chaharbakhshi E.O.
      • Perets I.
      • Ashberg L.
      • Mu B.
      • Lenkeit C.
      • Domb B.G.
      Do ligamentum teres tears portend inferior outcomes in patients with borderline dysplasia undergoing hip arthroscopic surgery? a match-controlled study with a minimum 2-year follow-up.
      • Chandrasekaran S.
      • Darwish N.
      • Martin T.J.
      • Suarez-Ahedo C.
      • Lodhia P.
      • Domb B.G.
      Arthroscopic capsular plication and labral seal restoration in borderline hip dysplasia: 2-Year clinical outcomes in 55 cases.
      ,
      • Cvetanovich G.L.
      • Levy D.M.
      • Weber A.E.
      • et al.
      Do patients with borderline dysplasia have inferior outcomes after hip arthroscopic surgery for femoroacetabular impingement compared with patients with normal acetabular coverage?.
      • Domb B.G.
      • Chaharbakhshi E.O.
      • Perets I.
      • Yuen L.C.
      • Walsh J.P.
      • Ashberg L.
      Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
      • Domb B.G.
      • Stake C.E.
      • Botser I.B.
      • Jackson T.J.
      Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: A prospective matched-pair study with average 2-year follow-up.
      ,
      • Kalisvaart M.M.
      • Safran M.R.
      Hip instability treated with arthroscopic capsular plication.
      ,
      • Maldonado D.R.
      • Perets I.
      • Mu B.H.
      • et al.
      Arthroscopic capsular plication in patients with labral tears and borderline dysplasia of the hip: Analysis of risk factors for failure.
      ,
      • Nawabi D.H.
      • Degen R.M.
      • Fields K.G.
      • et al.
      Outcomes after arthroscopic treatment of femoroacetabular impingement for patients with borderline hip dysplasia.
      ,
      • McClincy M.P.
      • Wylie J.D.
      • Yen Y.-M.
      • Novais E.N.
      Mild or borderline hip dysplasia: Are we characterizing hips with a lateral center-edge angle between 18° and 25° appropriately?.
      Because the diagnosis of BDDH relies primarily on a small range of LCEAs, even a minor offset can cause misdiagnosis, leading to the heterogeneity of the BDDH cohort. According to the definition by Wiberg,
      • Wiberg G.
      The anatomy and roentgenographic appearance of a normal hip joint.
      the LCEA is the angle formed by the vertical line along the longitudinal axis of the pelvis and the line connecting the center of the femoral head and the acetabular sourcil edge. However, inaccurate measurement of the LCEA is not uncommon. The most lateral point of the acetabulum rather than the sourcil edge is often used, which would cause a typical mistake with a falsely high LCEA value.
      • Ömeroglu H.
      • Biçimoglu A.
      • Aguş H.
      • Tümer Y.
      Measurement of center-edge angle in developmental dysplasia of the hip: A comparison of two methods in patients under 20 years of age.
      Besides, the congenital difference in LCEAs between male and female populations must not be neglected,
      • Beck E.C.
      • Nwachukwu B.U.
      • Chahla J.
      • et al.
      Patients with borderline hip dysplasia achieve clinically significant outcome after arthroscopic femoroacetabular impingement surgery: A case-control study with minimum 2-year follow-up.
      ,
      • Cvetanovich G.L.
      • Levy D.M.
      • Weber A.E.
      • et al.
      Do patients with borderline dysplasia have inferior outcomes after hip arthroscopic surgery for femoroacetabular impingement compared with patients with normal acetabular coverage?.
      which might have resulted in the superior outcomes of the female BDDH patients shown in the current review by Kuroda et al.
      • Kuroda Y.
      • Saito M.
      • Kumar K.H.S.
      • Malviya A.
      • Khanduja V.
      Arthroscopy and borderline developmental dysplasia of the hip: A systematic review.
      Although an LCEA slightly less than 25° may represent a significant structural abnormality in male patients, it is possibly a normal anatomic variant in female patients.
      • Beck E.C.
      • Nwachukwu B.U.
      • Chahla J.
      • et al.
      Patients with borderline hip dysplasia achieve clinically significant outcome after arthroscopic femoroacetabular impingement surgery: A case-control study with minimum 2-year follow-up.
      ,
      • Cvetanovich G.L.
      • Levy D.M.
      • Weber A.E.
      • et al.
      Do patients with borderline dysplasia have inferior outcomes after hip arthroscopic surgery for femoroacetabular impingement compared with patients with normal acetabular coverage?.
      ,
      • Kuroda Y.
      • Saito M.
      • Kumar K.H.S.
      • Malviya A.
      • Khanduja V.
      Arthroscopy and borderline developmental dysplasia of the hip: A systematic review.
      This difference clearly indicates a need to set different criteria for BDDH based on sex. Additionally, use of the LCEA alone as the standard of evaluation for BDDH has been questioned.
      • Nepple J.J.
      Editorial Commentary: At the intersection of borderline dysplasia and femoroacetabular impingement—Which way should we turn?.
      The LCEA merely allows evaluation of the lateral coverage of the acetabulum, whereas factors including anterior and posterior coverage and acetabular roof obliquity may also be powerful indicators of hip stability.
      • Wyatt M.C.
      • Beck M.
      The management of the painful borderline dysplastic hip.
      ,
      • Nepple J.J.
      Editorial Commentary: At the intersection of borderline dysplasia and femoroacetabular impingement—Which way should we turn?.
      In the meantime, an anatomic abnormality on the femoral side such as femoral anteversion should also be added to form comprehensive diagnostic criteria.
      • Chaharbakhshi E.O.
      • Hartigan D.E.
      • Perets I.
      • Domb B.G.
      Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
      ,
      • Wyatt M.C.
      • Beck M.
      The management of the painful borderline dysplastic hip.
      Second, identifying the fundamental cause of the symptoms in BDDH patients is critical in selecting suitable candidates for hip arthroscopy. As we know, the symptoms in BDDH patients might be attributed to mechanical lesions or functional hip instability. Mechanical lesions including labral tear, cam impingement, ligamentum teres tear, and capsular laxity can be managed using hip arthroscopy. However, because arthroscopy is rarely able to correct bony defects, PAO is needed to treat osseous hip instability in BDDH patients. Hip stability can be evaluated through a physical examination including the strength test, anterior and posterior apprehension signs, external rotation dial test, axial distraction test, and Beighton signs of hypermobility, among others.
      • Maranho D.
      • Fuchs K.
      • Kim Y-j
      • Novais E.N.
      Hip instability in patients with down syndrome.
      • Philippon M.J.
      • Briggs K.K.
      • Goljan P.
      • Peixoto L.P.
      The hip dial test to diagnose symptomatic hip instability.
      • Philippon M.J.
      • Patterson D.C.
      • Briggs K.K.
      Hip arthroscopy and femoroacetabular impingement in the pediatric patient.
      • Upasani V.V.
      CORR Insights: Periacetabular osteotomy improves pain and function in patients with lateral center-edge angle between 18° and 25°, but are these hips really borderline dysplastic?.
      • Canham C.D.
      • Domb B.G.
      • Giordano B.D.
      Atraumatic hip instability.
      Parameters measured on imaging are also important in the diagnosis of hip instability. For example, an acetabular index greater than 10°, femoral neck-shaft angle greater than 135°, femoral anteversion greater than 25°, acetabular labral hypertrophy, and ligamentum teres tear are all indicative of hip instability.
      • Abousamra O.
      • Bayhan I.A.
      • Rogers K.J.
      • Miller F.
      Hip instability in Down syndrome: A focus on acetabular retroversion.
      • Tibor L.M.
      • Liebert G.
      • Sutter R.
      • Impellizzeri F.M.
      • Leunig M.
      Two or more impingement and/or instability deformities are often present in patients with hip pain.
      • Kraeutler M.J.
      • Garabekyan T.
      • Pascual-Garrido C.
      • Mei-Dan O.
      Hip instability: A review of hip dysplasia and other contributing factors.
      • Dumont G.D.
      Hip instability: Current concepts and treatment options.
      • Laplaza F.J.
      • Root L.
      Femoral anteversion and neck-shaft angles in hip instability in cerebral palsy.
      • Spiegel D.A.
      • Flynn J.M.
      Evaluation and treatment of hip dysplasia in cerebral palsy.
      • Alter A.H.
      Myelodysplasia: The influence of the quadriceps and hip abductor muscles on ambulatory function and stability of the hip: C. W. Huff, P. L. Ramsey. J Bone Joint Surg 60A:432-443 (June), 1978.
      Moreover, parameters such as the femoro-epiphyseal acetabular roof index,
      • Wyatt M.
      • Weidner J.
      • Pfluger D.
      • Beck M.
      The femoro-epiphyseal acetabular roof (FEAR) index: A new measurement associated with instability in borderline hip dysplasia?.
      ,
      • Martin H.D.
      CORR Insights((R)): The femoro-epiphyseal acetabular roof (FEAR) index: A new measurement associated with instability in borderline hip dysplasia?.
      the iliocapsularis–to–rectus femoris ratio,
      • Haefeli P.C.
      • Steppacher S.D.
      • Babst D.
      • Siebenrock K.A.
      • Tannast M.
      An increased iliocapsularis-to-rectus-femoris ratio is suggestive for instability in borderline hips.
      and the iliofemoral line
      • Kraeutler M.J.
      • Ashwell Z.R.
      • Garabekyan T.
      • et al.
      The iliofemoral line: A radiographic sign of acetabular dysplasia in the adult hip.
      have recently been developed and shown to be effective in defining instability in the hip.
      Third, once hip arthroscopy is suggested for BDDH patients, the relative contraindications should be noted. From our experience, we learned that advanced age is the foremost risk factor in the prognosis. Therefore, we suggest that arthroscopic surgery should be cautiously applied to patients older than 40 years.
      • Chandrasekaran S.
      • Darwish N.
      • Martin T.J.
      • Suarez-Ahedo C.
      • Lodhia P.
      • Domb B.G.
      Arthroscopic capsular plication and labral seal restoration in borderline hip dysplasia: 2-Year clinical outcomes in 55 cases.
      ,
      • Domb B.G.
      • Chaharbakhshi E.O.
      • Perets I.
      • Yuen L.C.
      • Walsh J.P.
      • Ashberg L.
      Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
      ,
      • Domb B.G.
      • Stake C.E.
      • Botser I.B.
      • Jackson T.J.
      Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: A prospective matched-pair study with average 2-year follow-up.
      ,
      • Hatakeyama A.
      • Utsunomiya H.
      • Nishikino S.
      • et al.
      Predictors of poor clinical outcome after arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of borderline hip dysplasia.
      ,
      • Ding Z.
      • Sun Y.
      • Liu S.
      • Chen J.
      Hip arthroscopic surgery in borderline developmental dysplastic hips: A systematic review.
      It is also important to exclude patients with osteoarthritis or severe chondral lesions.
      • Chaharbakhshi E.O.
      • Perets I.
      • Ashberg L.
      • Mu B.
      • Lenkeit C.
      • Domb B.G.
      Do ligamentum teres tears portend inferior outcomes in patients with borderline dysplasia undergoing hip arthroscopic surgery? a match-controlled study with a minimum 2-year follow-up.
      ,
      • Chandrasekaran S.
      • Darwish N.
      • Martin T.J.
      • Suarez-Ahedo C.
      • Lodhia P.
      • Domb B.G.
      Arthroscopic capsular plication and labral seal restoration in borderline hip dysplasia: 2-Year clinical outcomes in 55 cases.
      ,
      • Domb B.G.
      • Chaharbakhshi E.O.
      • Perets I.
      • Yuen L.C.
      • Walsh J.P.
      • Ashberg L.
      Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
      ,
      • Evans P.T.
      • Redmond J.M.
      • Hammarstedt J.E.
      • Liu Y.
      • Chaharbakhshi E.O.
      • Domb B.G.
      Arthroscopic treatment of hip pain in adolescent patients with borderline dysplasia of the hip: Minimum 2-year follow-up.
      ,
      • Hatakeyama A.
      • Utsunomiya H.
      • Nishikino S.
      • et al.
      Predictors of poor clinical outcome after arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of borderline hip dysplasia.
      ,
      • Ding Z.
      • Sun Y.
      • Liu S.
      • Chen J.
      Hip arthroscopic surgery in borderline developmental dysplastic hips: A systematic review.
      Finally, arthroscopic procedures including acetabular labral repair, cam osteoplasty, capsular closure or plication, and intra-articular debridement are commonly performed in BDDH patients. Labral repair and capsular closure are strongly recommended to restore stability in BDDH patients.
      • Evans P.T.
      • Redmond J.M.
      • Hammarstedt J.E.
      • Liu Y.
      • Chaharbakhshi E.O.
      • Domb B.G.
      Arthroscopic treatment of hip pain in adolescent patients with borderline dysplasia of the hip: Minimum 2-year follow-up.
      ,
      • Fukui K.
      • Briggs K.K.
      • Trindade C.A.
      • Philippon M.J.
      Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia.
      ,
      • Nawabi D.H.
      • Degen R.M.
      • Fields K.G.
      • et al.
      Outcomes after arthroscopic treatment of femoroacetabular impingement for patients with borderline hip dysplasia.
      The advantage of fewer postoperative complications after hip arthroscopic procedures in BDDH patients has been validated in many short- to mid-term follow-up studies.
      • Beck E.C.
      • Nwachukwu B.U.
      • Chahla J.
      • et al.
      Patients with borderline hip dysplasia achieve clinically significant outcome after arthroscopic femoroacetabular impingement surgery: A case-control study with minimum 2-year follow-up.
      • Byrd J.W.
      • Jones K.S.
      Hip arthroscopy in the presence of dysplasia.
      • Chaharbakhshi E.O.
      • Hartigan D.E.
      • Perets I.
      • Domb B.G.
      Is hip arthroscopy effective in patients with combined excessive femoral anteversion and borderline dysplasia? A match-controlled study.
      • Chaharbakhshi E.O.
      • Perets I.
      • Ashberg L.
      • Mu B.
      • Lenkeit C.
      • Domb B.G.
      Do ligamentum teres tears portend inferior outcomes in patients with borderline dysplasia undergoing hip arthroscopic surgery? a match-controlled study with a minimum 2-year follow-up.
      • Chandrasekaran S.
      • Darwish N.
      • Martin T.J.
      • Suarez-Ahedo C.
      • Lodhia P.
      • Domb B.G.
      Arthroscopic capsular plication and labral seal restoration in borderline hip dysplasia: 2-Year clinical outcomes in 55 cases.
      • Christensen J.C.
      • Marland J.D.
      • Miller C.J.
      • Horton B.S.
      • Whiting D.R.
      • West H.S.
      Trajectory of clinical outcomes following hip arthroscopy in female subgroup populations.
      • Cvetanovich G.L.
      • Levy D.M.
      • Weber A.E.
      • et al.
      Do patients with borderline dysplasia have inferior outcomes after hip arthroscopic surgery for femoroacetabular impingement compared with patients with normal acetabular coverage?.
      ,
      • Domb B.G.
      • Stake C.E.
      • Botser I.B.
      • Jackson T.J.
      Surgical dislocation of the hip versus arthroscopic treatment of femoroacetabular impingement: A prospective matched-pair study with average 2-year follow-up.
      • Evans P.T.
      • Redmond J.M.
      • Hammarstedt J.E.
      • Liu Y.
      • Chaharbakhshi E.O.
      • Domb B.G.
      Arthroscopic treatment of hip pain in adolescent patients with borderline dysplasia of the hip: Minimum 2-year follow-up.
      • Fukui K.
      • Briggs K.K.
      • Trindade C.A.
      • Philippon M.J.
      Outcomes after labral repair in patients with femoroacetabular impingement and borderline dysplasia.
      • Garabekyan T.
      • Ashwell Z.
      • Chadayammuri V.
      • et al.
      Lateral acetabular coverage predicts the size of the hip labrum.
      • Hatakeyama A.
      • Utsunomiya H.
      • Nishikino S.
      • et al.
      Predictors of poor clinical outcome after arthroscopic labral preservation, capsular plication, and cam osteoplasty in the setting of borderline hip dysplasia.
      • Ishøi L.
      • Thorborg K.
      • Kraemer O.
      • Lund B.
      • Mygind-Klavsen B.
      • Hölmich P.
      Demographic and radiographic factors associated with intra-articular hip cartilage injury: A cross-sectional study of 1511 hip arthroscopy procedures.
      • Kalisvaart M.M.
      • Safran M.R.
      Hip instability treated with arthroscopic capsular plication.
      • Kalore N.V.
      • Jiranek W.A.
      Save the torn labrum in hips with borderline acetabular coverage.
      • Kaya M.
      • Suzuki T.
      • Emori M.
      • Yamashita T.
      Hip morphology influences the pattern of articular cartilage damage.
      • Maldonado D.R.
      • Perets I.
      • Mu B.H.
      • et al.
      Arthroscopic capsular plication in patients with labral tears and borderline dysplasia of the hip: Analysis of risk factors for failure.
      • Matsuda D.K.
      • Kivlan B.R.
      • Nho S.J.
      • et al.
      Arthroscopic outcomes as a function of acetabular coverage from a large hip arthroscopy study group.
      • Nawabi D.H.
      • Degen R.M.
      • Fields K.G.
      • et al.
      Outcomes after arthroscopic treatment of femoroacetabular impingement for patients with borderline hip dysplasia.
      • Ohnishi Y.
      • Suzuki H.
      • Nakashima H.
      • et al.
      Radiologic correlation between the ischiofemoral space and morphologic characteristics of the hip in hips with symptoms of dysplasia.
      • Wyatt M.
      • Weidner J.
      • Pfluger D.
      • Beck M.
      The femoro-epiphyseal acetabular roof (FEAR) index: A new measurement associated with instability in borderline hip dysplasia?.
      • Yoon S.J.
      • Lee S.H.
      • Jang S.W.
      • Jo S.
      Hip arthroscopy of a painful hip with borderline dysplasia.
      Meanwhile, it is apparent that suboptimal outcomes increase as the follow-up period increases and could reach an overall rate of 33% according to a 5-year follow-up study.
      • Domb B.G.
      • Chaharbakhshi E.O.
      • Perets I.
      • Yuen L.C.
      • Walsh J.P.
      • Ashberg L.
      Hip arthroscopic surgery with labral preservation and capsular plication in patients with borderline hip dysplasia: Minimum 5-year patient-reported outcomes.
      ,
      • Nepple J.J.
      Editorial Commentary: At the intersection of borderline dysplasia and femoroacetabular impingement—Which way should we turn?.
      More long-term high-grade evidence is needed to analyze the impact of different characteristics of BDDH patients on their prognosis after arthroscopy to form a detailed description of which BDDH patients can achieve optimal results with arthroscopy. In addition, we believe that it is necessary to establish a staged treatment protocol based on an accurate diagnosis of BDDH. With the help of technological advances in imaging and biomechanical simulation, we hope to be able to clarify these 3 major questions in each BDDH patient: Is the developmental dysplasia of the hip really borderline? Do the major symptoms result from hip instability? Can soft-tissue management alone solve the present and prospective problems? Only then can we determine what stage the diseased hip is at and offer a patient-specific treatment plan. We believe that an individualized treatment strategy will bring optimal outcomes for BDDH patients.

      Supplementary Data

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