Why look to the future?

Why look to the future? We look to the future to challenge the existing state of affairs. The practice of medicine is fluid, and thus, what we practice today will surely be different than what we practice tomorrow. The ability to synthesize, disseminate, implement and monitor emerging evidence is critical to ensure medicine moves forward while upholding best practices and patient-centred care. This notion is particularly important for hip arthroscopy, which is a relatively young field with several remaining core knowledge gaps.

Initially, hip arthroscopy was mainly diagnostic, but better understanding of the pathology, improved examination techniques and imaging modalities have led to an increasing proportion of therapeutic procedures coupled with the recognition of new pathologies. This expanding list of hip conditions includes symptomatic labral tears, chondral lesions, femoroacetabular impingement (FAI), injuries of the ligamentum teres, instability, and various extra-articular hip disorders. While there has been a substantial increase in both arthroscopic hip procedures and research throughout the world (1,2), there remains a paucity of evidence to support the indications and benefits of surgical versus non-surgical management of FAI. However, several multi-center randomized trials currently underway may provide some insights: trial of arthroscopic surgery for hip impingement versus best conventional care (UK FASHION), the FemoroAcetabular Impingement Trial (FAIT) and the Femoroacetabular Impingement RandomiSed Controlled Trial (FIRST) (3-5). While some non-arthritic hip surgery registries exist (British Non-Arthroplasty Hip Registry and the Danish Hip Arthroscopy Register), more are needed, as their contribution to epidemiological research and monitoring of long-term clinical outcomes will prove invaluable.

Prophylactic hip arthroscopy to correct hip impingement is currently not recommended. The progression from asymptomatic FAI on incidental radiographs to FAI syndrome (FAIS), and finally osteoarthritis remains incompletely understood and longitudinal studies are needed to establish risk factors of disease progression (6). While various cut-offs used to define cam and pincer-type impingement have been proposed, it is plausible that the true threshold for FAIS “expression” is largely influenced by a combination of morphological parameters, genetics, and cultural habits and activities. The role of quantitative and biological chondral imaging modalities needs further investigation, in particular whether early detection and changes post-operatively correlate with better functional outcomes and long-term progression. Biologic therapies have emerged as a new or adjunctive modality to improve clinical outcomes of hip pathology, as well as, innovative techniques to repair chondral damage and restore the form and function of the labrum. Lastly, while the future of hip arthroscopy is bright, the learning curve is prolonged, and therefore valid and reliable teaching and assessment tools will be essential to prepare young surgeons to effectively apply the emerging evidence of tomorrow.

Acknowledgments

We would like to thank all the authors included in this special hip focused issue for their contribution to this journal and the field of hip preservation research.

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Joint for the series “Future Perspectives in Hip Preservation and Arthroscopy”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/aoj.2018.05.02). The series “Future Perspectives in Hip Preservation and Arthroscopy” was commissioned by the editorial office without any funding or sponsorship. RPC served as the unpaid Guest Editor of the series. ORA served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Annals of Joint from Aug 2017 to Jul 2019. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Khan M, Oduwole KO, Razdan P, et al. Sources and quality of literature addressing femoroacetabular impingement: a scoping review 2011-2015. Curr Rev Musculoskelet Med 2016;9:396-401. [Crossref] [PubMed]
2. Maradit Kremers H, Schilz SR, Van Houten HK, et al. Trends in Utilization and Outcomes of Hip Arthroscopy in the United States Between 2005 and 2013. J Arthroplasty 2017;32:750-5. [Crossref] [PubMed]
3. Griffin DR, Dickenson EJ, Wall PD, et al. Protocol for a multicentre, parallel-arm, 12-month, randomised, controlled trial of arthroscopic surgery versus conservative care for femoroacetabular impingement syndrome (FASHIoN). BMJ Open 2016;6:e012453 [Crossref] [PubMed]
4. Palmer AJ, Ayyar-Gupta V, Dutton SJ, et al. Protocol for the Femoroacetabular Impingement Trial (FAIT): a multi-centre randomised controlled trial comparing surgical and non-surgical management of femoroacetabular impingement. Bone Joint Res 2014;3:321-7. [Crossref] [PubMed]
5. FIRST Investigators. A multi-centre randomized controlled trial comparing arthroscopic osteochondroplasty and lavage with arthroscopic lavage alone on patient important outcomes and quality of life in the treatment of young adult (18-50) femoroacetabular impingement. BMC Musculoskelet Disord 2015;16:64. [Crossref] [PubMed]
6. Griffin DR, Dickenson EJ, O'Donnell J, et al. The Warwick Agreement on femoroacetabular impingement syndrome (FAI syndrome): an international consensus statement. Br J Sports Med 2016;50:1169-76. [Crossref] [PubMed]

Olufemi R. Ayeni

Ryan P. Coughlin