Top Ten Pearls for Successful Hip Arthroscopy for Femoroacetabular Impingement

Basics of hip arthroscopy: Step-by-step technique

Hip arthroscopy is a surgical procedure that has a technically challenging nature, requiring advanced spatial skills and specialised instrumentation. The most common indication for hip arthroscopy is femoroacetabular impingement, which is increasing due to improved awareness and knowledge of the condition among healthcare professionals. Hip arthroscopy requires many different checkpoints from patient positioning to capsule closure to be successfully completed. Patient positioning is one of the keystones of hip arthroscopy and the probability of a surgeon achieving successful outcomes is significantly influenced by the establishment of optimal access points. The importance of the acetabular labrum and capsule has been better understood in recent years. There has been a noticeable preference towards prioritising acetabular labral repair over debridement or excision. Similarly, consistent with the literature, capsule closure restores naive hip biomechanics more successfully and improves functional outcomes following hip arthroscopy. Osteochondroplasty is a frequently employed therapeutic intervention; yet, attaining optimal osteochondroplasty outcomes might present challenges. The aim is, to restore the full perfect sphericity of the femoral head without attenuation of the head. The aim of this article is to highlight the knowledge accumulated from experiences based on previous hip arthroscopy surgeries as a solution for future troubleshooting steps. Level of Evidence: Level V.

Capsular Management at the Time of Hip Arthroscopy for Femoroacetabular Impingement Syndrome Varies With Geography and Surgeon Subspecialty Training: A Cross-Sectional, Multinational Surgeon Survey

PURPOSE

To perform a multinational survey and identify patterns in capsular management at the time of hip arthroscopy.

METHODS

An anonymous, nonvalidated survey was distributed by the American Orthopaedic Society for Sports Medicine; Arthroscopy Association of North America; European Society of Sports Traumatology, Knee Surgery & Arthroscopy; International Society for Hip Arthroscopy; and Turkish Society of Sports Traumatology, Arthroscopy, and Knee Surgery. The questions were broken down into 6 categories: demographic characteristics, capsulotomy preference, traction stitches, capsular closure, postoperative rehabilitation, and postoperative complications.

RESULTS

The survey was completed by 157 surgeons. Surgeons who performed half or full T-type capsulotomies had 2.4 higher odds of using traction sutures for managing both the peripheral and central compartments during hip arthroscopy for femoroacetabular impingement (P = .024). Surgeons who believed that there was sufficient literature regarding the importance of hip capsular closure had 1.9 higher odds of routinely performing complete closure of the capsule (P = .044). Additionally, surgeons who practiced in the United States had 8.1 higher odds of routinely closing the capsule relative to international surgeons (P < .001). Moreover, surgeons who received hip arthroscopy training in residency or fellowship had 2.4 higher odds of closing the capsule completely compared with surgeons who did not have exposure to hip arthroscopy during their training (P = .009).

CONCLUSIONS

Geographic and surgeon-related variables correlate with capsular management preferences during hip arthroscopy. Surgeons who perform half or full T-capsulotomies more often use traction stitches for managing both the peripheral and central compartments. Surgeons performing routine capsular closure are more likely to believe that sufficient evidence is available to support the practice, with surgeons in the United States being more likely to perform routine capsular closure in comparison to their international colleagues.

CLINICAL RELEVANCE

As the field of hip preservation continues to evolve, capsular management will likely continue to play an important role in access, instrumentation, and postoperative outcomes.

Hip Capsular Reconstruction With Indirect Head of the Rectus Femoris Tendon

Hip capsulotomy is performed during arthroscopic hip procedures to achieve adequate visualization of the joint and instrument access. The hip capsule, and in particular the iliofemoral ligament, is an important stabilizer of the hip joint, and patients who undergo capsulotomy without subsequent repair may experience hip pain and instability, with increased risk of requiring revision hip arthroscopy. Therefore, restoring watertight closure of the capsule is necessary to restore native biomechanics and achieve desired postoperative outcomes. Although primary repair or plication suffice in most cases, capsule reconstruction may instead be necessary when there is insufficient tissue, often due to capsular insufficiency following index surgery. The purpose of this Technical Note is to describe the authors' current technique for arthroscopic hip capsular reconstruction using the indirect head of the rectus femoris tendon in the setting of capsular iatrogenic hip instability, as well as its advantages and disadvantages and technical pearls and pitfalls.

Noninvasive shape-fitting method quantifies cam morphology in femoroacetabular impingement syndrome: Implications for diagnosis and surgical planning

There are considerable limitations associated with the standard 2D imaging currently used for the diagnosis and surgical planning of cam-type femoroacetabular impingement syndrome (FAIS). The aim of this study was to determine the accuracy of a new patient-specific shape-fitting method that quantifies cam morphology in 3D based solely on preoperative MRI imaging. Preoperative and postoperative 1.5T MRI scans were performed on n = 15 patients to generate 3D models of the proximal femur, in turn used to create the actual and the virtual cam. The actual cams were reconstructed by subtracting the postoperative from the preoperative 3D model and used as reference, while the virtual cams were generated by subtracting the preoperative 3D model from the virtual shape template produced with the shape-fitting method based solely on preoperative MRI scans. The accuracy of the shape-fitting method was tested on all patients by evaluating the agreement between the metrics of height, surface area, and volume that quantified virtual and actual cams. Accuracy of the shape-fitting method was demonstrated obtaining a 97.8% average level of agreement between these metrics. In conclusion, the shape-fitting technique is a noninvasive and patient-specific tool for the quantification and localization of cam morphology. Future studies will include the implementation of the technique within a clinically based software for diagnosis and surgical planning for cam-type FAIS.