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Editorial Commentary: Successful Revision Hip Arthroscopy Requires Accurate Diagnosis of the Cause of Failure: “One-Size-Fits-All Surgery Is Not Appropriate”

      Abstract

      As hip arthroscopy increases in scope and quantity, treatment options for patients who did not respond to primary surgery expand as well. As our techniques improve and become more nuanced, it is crucial that our understanding of individual patients’ root cause pathology keeps pace to ensure that the right patients get the right surgery.
      Our understanding of mechanical hip pain has grown in nuance in recent years. As this understanding has grown, so has our capacity to help a growing number of patients. How many patients have experienced the crushing frustration of being told that their hip pain is “just a groin strain” or a “chronic flexor tendon irritation” or worst yet, “just in their head?” Our comprehension of the complex interplay between hip impingement, inflammation, and microinstability of the hip means that more patients can potentially be helped. Patient-specific arthroscopic treatment creates an opportunity to help more people to their functional goals.
      Increasing understanding and ability leads to increased clinical comfort, which will only naturally increase the volume of hip arthroscopies performed. More hip arthroscopies does unfortunately mean more patients with failures of primary treatment, a risk for even the most successful of surgeries.
      • Cevallos N.
      • Soriano K.K.J.
      • Flores S.E.
      • Wong S.E.
      • Lansdown D.A.
      • Zhang A.L.
      Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
      We must turn our focus to aiding those patients who did not get the response they desired from the first go-around. In the instance of such patients with recurrent microinstability secondary to failed labral treatment, Doctors Maldonaldo, Ouyang, Lee, Jimenez, Sabetian, Saks, Lall, and Domb
      • Maldonado D.
      • Ouyang V.
      • Lee M.
      • et al.
      After revision hip arthroscopy, patients having either circumferential or segmental labral reconstructions for the management of irreparable labra show clinical improvement based on proper indications.
      do much to expand our understanding in their recent publication. “After Revision Hip Arthroscopy, Patients Having Either Circumferential or Segmental Labral Reconstructions for the Management of Irreparable Labra Show Clinical Improvement Based on Proper Indications” is an impressive illustration of how far we have come in revision hip arthroscopy.
      One of the key findings that stands out to me is the comparable, positive outcomes for both patients undergoing circumferential and segmental labral reconstruction.
      • Maldonado D.
      • Ouyang V.
      • Lee M.
      • et al.
      After revision hip arthroscopy, patients having either circumferential or segmental labral reconstructions for the management of irreparable labra show clinical improvement based on proper indications.
      Given that this was a cohort study and not a randomized trial, the implication is that each patient received what was determined to be the appropriate surgery for their specific labral findings. As such, we begin to see that when the surgeon performs the right surgery for the right pathology, durable outcomes can be expected. While this is certainly not a novel concept, it does serve as a reminder that “one-size-fits-all” surgery is not appropriate for hip arthroscopy (nor is it for any arthroscopic procedure). The burden remains on us to continue expanding our ability to identify a given patient’s root cause pathology. That may mean microinstability related to labral insufficiency, as is the case for this study. It could mean capsular laxity or deficiency from a previous unclosed capsulotomy.
      • Maldonado D.R.
      • Chen J.W.
      • Yelton M.J.
      • et al.
      Achieving successful outcomes of hip arthroscopy in the setting of generalized ligamentous laxity with labral preservation and appropriate capsular management: A propensity matched controlled study.
      ,
      • Looney A.M.
      • McCann J.A.
      • Connolly P.T.
      • Comfort S.M.
      • Curley A.J.
      • Postma W.F.
      Routine capsular closure with hip arthroscopic surgery results in superior outcomes: A systematic review and meta-analysis.
      It could be subtle alterations of acetabular and femoral version that resulted in previously undiagnosed causes for impingement or effective dysplasia.
      • Alter T.D.
      • Kunze K.N.
      • Newhouse A.C.
      • et al.
      Assessment of femoral torsion on magnetic resonance imaging is more reliable using axial-oblique sequences compared with standard axial slices in patients with femoroacetabular impingement syndrome.
      The more effort we put into identifying the specific cause of patient symptoms, the better we can help a wider variety of those with mechanical hip pain.

      Supplementary Data

      References

        • Cevallos N.
        • Soriano K.K.J.
        • Flores S.E.
        • Wong S.E.
        • Lansdown D.A.
        • Zhang A.L.
        Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
        Arthroscopy. 2021; 37: 3445-3454.e3441
        • Maldonado D.
        • Ouyang V.
        • Lee M.
        • et al.
        After revision hip arthroscopy, patients having either circumferential or segmental labral reconstructions for the management of irreparable labra show clinical improvement based on proper indications.
        Arthroscopy. 2022; 38: 2459-2469
        • Maldonado D.R.
        • Chen J.W.
        • Yelton M.J.
        • et al.
        Achieving successful outcomes of hip arthroscopy in the setting of generalized ligamentous laxity with labral preservation and appropriate capsular management: A propensity matched controlled study.
        Am J Sports Med. 2020; 48: 1625-1635
        • Looney A.M.
        • McCann J.A.
        • Connolly P.T.
        • Comfort S.M.
        • Curley A.J.
        • Postma W.F.
        Routine capsular closure with hip arthroscopic surgery results in superior outcomes: A systematic review and meta-analysis.
        Am J Sports Med. 2021; (3635465211023508)
        • Alter T.D.
        • Kunze K.N.
        • Newhouse A.C.
        • et al.
        Assessment of femoral torsion on magnetic resonance imaging is more reliable using axial-oblique sequences compared with standard axial slices in patients with femoroacetabular impingement syndrome.
        Arthroscopy. 2022; 38: 1857-1866