Editorial.

An eminent London hip surgeon has been known to tell his audiences that hip replacement and periacetabular osteotomy (PAO) are ‘powerful operations’. While the term ‘powerful operation’ is not often used in medical practice, it does conjure up images of interventions that are reliable and life-changing.

Hip replacement can restore an individual with severe pain and restricted mobility to normality. Degenerative hip disease besets any society in which life expectancy exceeds 50 years and the benefits of hip replacement are unequivocal. Many patients articulate their appreciation of hip replacement as having ‘given them back their life’ and we can quantify this benefit by citing the change in pre- to post-operative scores through patient reported outcome measures (PROMS) [1-3] and clinical assessment instruments [4, 5].

Likewise, the sequelae of hip dysplasia have long been recognized both in terms of disability and disease progression to premature hip degeneration [6, 7]. PAO has been developed as an evolutionary improvement of earlier acetabular realignment procedures [8]. Over the last few decades, PAO has become a less intrusive intervention [9], with a shorter period of hospitalization and more consistent, predictable outcomes. In consequence, few practitioners, health economists or healthcare funders dispute its value.

In contrast, hip arthroscopy is a relatively new technique that, prior to the recognition of femoroacetabular impingement, was viewed by many as a surgical curio. Unlike the surgeons who have developed laparoscopic cholecystectomy and hernia repair or arthroscopic meniscectomy, shoulder stabilization, rotator cuff repair or arthroscopic-assisted cruciate reconstruction, hip surgeons did not have a preexisting surgical intervention that could be better undertaken arthroscopically. In consequence, hip preservation surgeons have faced the challenges of accessing and instrumenting the most deeply situated joint in the body, proving the need to treat previously unrecognized conditions, proving that surgical treatment provides greater benefit than non-surgical alternatives [10-12], proving that the benefits of arthroscopic interventions can be long lasting [13], identifying the limitations of arthroscopic interventions [14, 15] and demonstrating that such interventions improve quality of life enough to justify their cost [16].

As attention to the COVID-19 pandemic recedes, healthcare purchasers will need to identify where their resources are best spent. Hip preservation surgeons will need to demonstrate that their interventions are as beneficial and cost effective as other competing healthcare interventions. JHPS is the only journal dedicated to hip preservation surgery and I urge you to focus your attention on designing, resourcing, undertaking and submitting manuscripts on robust studies that better enable healthcare purchasers quantify the clinical and economic benefits of our work.

My first pick from JHPS issue 9.1 is a wonderful paper from Anil Ranawat’s team at the Hospital for Special Surgery [17]. Their study is rich in outcomes data and provides robust evidence that when hip arthroscopy is undertaken, patients with at least one self-reported allergy have significantly higher rates of subsequent hip surgery, with almost 25% of the allergy cohort undergoing subsequent surgery versus less than 10% of the control cohort. The study also serves as an exemplar for the diligent data capture that will be increasingly valuable to best understand and document the benefits and shortcomings of hip preservation surgery.

My second pick is from Olufemi Ayeni’s team, at McMaster, who provide a paper on sexual and urinary function post-surgical treatment of femoroacetabular impingement [18]. It is a gem of scientific investigation into an area that we all want to know about and be able to advise our patients. It provides us with information that we need to reassure anxieties, dispel myths and ensure that patients have the information that they need to provide informed consent for surgery. The paper provides reassuring evidence that an hour of hip traction does not cause urinary incontinence and that men undergoing femoral osteochondroplasty can look forward to improved sexual function a year after their surgery.

My third pick is a paper from the Mayo clinic team on risk factors for long-term hip osteoarthritis in patients with hip dysplasia without surgical intervention [19]. It is always difficult to advise patients with radiological evidence of hip dysplasia whether joint degeneration is inevitable and, if so, how long their natural hips will last. While every patient’s circumstances are unique, this paper enables us to tell such patients that only 1 in 5 will develop OA in the next decade and that only 1 in 10 will progress to hip replacement in this period. However, patients who are overweight or in their mid-thirties are best advised to prepare for a less optimistic prognosis.

I hope that you enjoy reading all the papers in this issue and that you will feel inspired to engage in research projects to document and report the outcome of the hip preservation procedures that you undertake for your patients.