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Editorial Commentary: Post-Free Arthroscopy Reduces Complications and Pain: To Post or Not to Post? Is That Still a Question?

      Abstract

      Post-free hip arthroscopy has garnered much attention over the past several years. The attraction of eliminating groin complications is at the forefront of this technique. Recent studies have shown improved blood flow, safe techniques, but other benefits, if any, are yet to be discovered. For now, those adopting post-free distraction do so to eliminate a source of groin complication, improved access to the cam, and a perceived decrease in pain. Several options exist to achieve post-free distraction, and, as we continue to perfect this technique, continued studies may reveal other advantages or disadvantages to post removal.
      With the introduction of post-free hip arthroscopy, the hip preservation community is left with a conundrum, change an operation to eliminate a potential groin complication or continue the procedure as known.
      • Mei-Dan O.
      • McConkey M.O.
      • Young D.A.
      Hip arthroscopy distraction without the use of a perineal post: prospective study.
      • Kollmorgen R.C.
      • Ellis T.
      • Lewis B.D.
      • Harris J.D.
      Achieving post-free distraction in hip arthroscopy with a pink pad patient positioning device using standard hip distraction tables.
      • Larson C.M.
      • Clohisy J.C.
      • Beaule P.E.
      • et al.
      Intraoperative and early postoperative complications after hip arthroscopic surgery: A prospective multicenter trial utilizing a validated grading scheme.
      New techniques involves a learning curve, questions on safety, and begs the question, “Is it worth it?” Hip arthroscopy is already a highly technical procedure, and introducing a new technique may cause surgeon discomfort and could lead to iatrogenesis imperfecta.
      • Harris J.D.
      • Brand J.C.
      • Rossi M.J.
      • Leland J.M.
      • Lubowitz J.H.
      Iatrogenic arthroscopic cartilage injury: Arthroscrapes result from iatrogenesis imperfecta.
      However, patient safety is of paramount importance, and known potential groin complications are what we all try to avoid.
      • Frandsen L.
      • Lund B.
      • Grønbech Nielsen T.
      • Lind M.
      Traction-related problems after hip arthroscopy.
      ,
      • Kern M.J.
      • Murray R.S.
      • Sherman T.I.
      • Postma W.F.
      Incidence of nerve injury after hip arthroscopy.
      With removing the post, we eliminate the possibility of iatrogenic groin injury, but we must ask ourselves, is changing our technique necessary? Those already adopting post-free think so, but studies are needed to show safety and efficacy of post-less arthroscopy.
      As a post-free surgeon, I was excited to review “Hip Arthroscopy With and Without a Perineal Post: A Comparison of Postoperative Pain.
      • Schaver A.L.
      • Mattingly N.
      • Glass N.A.
      • Willey M.C.
      • Westermann R.W.
      Hip arthroscopy with and without a perineal post: A comparison of early postoperative pain.
      Schaver, Mattingly, Glass, Willey, and Westermann delivered a Level III single surgeon retrospective comparisons study evaluating the effects of postless distraction. The study entailed 2 cohorts with 100 post patients versus 100 patients after the conversion to post-free. The team evaluated operative time, narcotic use, pain, and time to discharge. They concluded post-free distraction yielded significantly quicker operating room (OR) time (11 minutes), faster time to discharge (40 minutes), and each group had similar pain scores and narcotic consumption. More importantly post-free distraction showed no groin complications, no iatrogenic access injuries, and no patient safety issues.
      The less we pull on the groin through the post, it would be intuitive to possibly improve the patient’s pain experience if the post is eliminated. In our current study, both groups underwent an operation so subjective pain scores may not be different at the same time points, but post-free patients were shown to be discharged faster. Are patients going home more quickly because of less pain? Quicker OR time because of easier cam access? The decreased operative time the authors observed is not surprising. For me, without the post, the cam access is easier and may account for the observed decreased OR time.
      The visual analog scores (VAS) the authors used were the first on admission and last scores from the postanesthesia care unit. The VAS has known limitations, and the nature of how and when asked to postsurgical patients must be kept in mind.
      • Bijur P.E.
      • Latimer C.T.
      • Gallagher E.J.
      Validation of a verbally administered numerical rating scale of acute pain for use in the emergency department.
      At the first pain score rating, the patients are just out of anesthesia and may not be representative of the entire pain experience. Most institutions for outpatient surgeries have criteria for discharge (VAS less than a certain number), and the VAS at discharge from the postanesthesia care unit should be similar for both groups, as it was for our current study. Possibly the post group took longer to meet the discharge VAS score because of increased pain. What would also be relevant are the mean pain and maximum pain scores, and therein may lay a benefit of post-free technique. Regardless, be it pain or not pulling through a post, the patients were discharged 40 minutes sooner with a post-free technique.
      In my own experience, I have found post-free patients show a decreased VAS mean and VAS max scores with no difference in OR time, time to discharge, nor narcotic use when compared to a previous post cohort. Although my data, submitted for publication and under peer review, shows decreased pain, whereas the current study does not, which alludes to differences in VAS score collection methods. Regardless of post-free distraction technique, there have been no reported patient safety nor groin complications, and importantly our current study noted no safety issues with conversion to post-free distraction.
      If one moves to post-free, there are several technical tricks that can lead to success. Type of distractor, Guardian table or conventional table with the pink pad technique, is based on surgeon preference and facility resources.
      • Kollmorgen R.C.
      • Ellis T.
      • Lewis B.D.
      • Harris J.D.
      Achieving post-free distraction in hip arthroscopy with a pink pad patient positioning device using standard hip distraction tables.
      ,
      • Mei-Dan O.
      • Kraeutler M.J.
      • Garabekyan T.
      • Goodrich J.A.
      • Young D.A.
      Hip distraction without a perineal post: A prospective study of 1000 hip arthroscopy cases.
      Both are effective means for achieving postless distraction. More importantly, attention to proper patient positioning on the table, boot padding, using the air arthrogram to break the suction seal, achieving safe distraction, and expert access is paramount.
      • Kollmorgen R.C.
      • Ellis T.
      • Lewis B.D.
      • Harris J.D.
      Achieving post-free distraction in hip arthroscopy with a pink pad patient positioning device using standard hip distraction tables.
      If these events are properly executed, adoption of the technique comes with ease, and if a single groin complication is avoided, the learning curve is not in vain. As our authors state, their learning curve was not as steep as expected, and this is consistent with my own experience, with 5 to 10 cases to adjust.
      • Schaver A.L.
      • Mattingly N.
      • Glass N.A.
      • Willey M.C.
      • Westermann R.W.
      Hip arthroscopy with and without a perineal post: A comparison of early postoperative pain.
      Whether to embrace post-free is multifactorial, and in the end, it’s still hip arthroscopy. The expert skill needed to execute the procedure comes first, and safely eliminating a rare groin complication is the benefit of the post-free technique. At the end of the day, to post or not to post? If we avoid a groin complication, is there still a question? I say, “Move post, get out the way.” I would encourage any surgeon to come visit a post-free surgeon before eliminating the post, because sharing knowledge can help with surgeon comfort.

      Supplementary Data

      References

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        Achieving post-free distraction in hip arthroscopy with a pink pad patient positioning device using standard hip distraction tables.
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        Intraoperative and early postoperative complications after hip arthroscopic surgery: A prospective multicenter trial utilizing a validated grading scheme.
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