This outstanding study brings into focus an important problem in the world of hip preservation — that of the patient with persistent pain after PAO — and highlights the need for caution in surgical indications and choice of surgical procedures. In some cases, pain may arise from pathologies that can be treated arthroscopically, such as a tear of the labrum, unstable cartilage flap or FAI induced by overcorrection. Indeed, overcorrected PAOs led, in part, to the discovery of FAI.
In other cases, global degeneration of a hip after PAO may render futile any further attempts to preserve the hip, whether by arthroscopic means or otherwise. Some such cases may be better addressed with arthroplasty.
Today’s workup requires 3D evaluation of the bony anatomy, advanced imaging of cartilage, such as dGEMRIC, and comprehensive understanding of patient factors to appropriately indicate hip preservation vs. THR. Furthermore, advanced arthroscopic techniques, such as anatomic labral repair, segmental or circumferential labral reconstruction, capsular plication and precision in FAI correction, may enable more successful results of arthroscopy in challenging revision cases.
Finally, the emergence of concomitant PAO and arthroscopy may avoid need for subsequent arthroscopy, having made it possible to treat intra-articular pathologies at the time of the index PAO surgery, including labral tears, chondral flaps and cam-type FAI. To conclude, thorough workup, careful indications and an arsenal of surgical techniques in both hip arthroscopy and arthroplasty are required to meet the challenges presented by persistent pain after PAO.
Benjamin G. Domb, MD, FAAOS, FAOA
Founder and medical director of American Hip Institute
Chair and fellowship director of American Hip Institute Research Foundation
Disclosures: Domb reports he has had ownership interests in Hinsdale Orthopaedics, the American Hip Institute, SCD#3, North Shore Surgical Suites and Munster Specialty Surgery Center; has received research support from Arthrex, ATI, the Kaufman Foundation, Pacira Pharmaceuticals and Stryker; received consulting fees from Adventist Hinsdale Hospital, Arthrex, Mako Surgical, Medacta, Pacira Pharmaceuticals and Stryker; educational support from Arthrex, Breg and Medwest; royalties from Arthrex, DJO Global, Mako Surgical, Stryker and Orthomerica; and speaking fees from Arthrex and Pacira Pharmaceuticals.