Navigating the Next Decade of Hip Preservation

The study by Nepple et al. on the long-term outcomes of open and arthroscopic hip preservation surgery for femoroacetabular impingement (FAI) is a timely and critical addition to the literature. As evidence confirms that untreated symptomatic FAI accelerates the risk of osteoarthritis1, robust longitudinal data are essential to guide and improve our interventions for it. So where are we now? Although long-term outcome data remain relatively scarce, the landscape of FAI treatment has shifted. Open surgical dislocation is now typically reserved for complex deformities, and hip arthroscopy has firmly established itself as the gold standard. However, as our understanding of complex pathomorphologies evolves, the indications for both advanced arthroscopic and open techniques continue to be refined. The multicenter design of the present study, unlike the predominantly single-surgeon cohorts in the existing literature, adds substantial weight to its findings. Nepple et al. demonstrated 90.6% survivorship free of total hip arthroplasty (THA) at a mean 10-year follow-up, and they identified age, obesity (body mass index BMI ≥ 30 kg/m2), male sex, and femoral head chondromalacia as key risk factors for conversion to THA. These results are highly encouraging and validate our current hip preservation efforts, even as surgical techniques have advanced considerably since the study’s inception. And so where do we need to go? To further improve our long-term outcomes, we must address 4 critical areas. First, we need to evolve past radiographs: The reliance on the radiographic Tönnis classification as the primary determinant of cartilage health, and thereby the ultimate indication or contraindication for preservation, is increasingly obsolete. As demonstrated by Lerch et al. and Kuhns et al.2,3, chondral and labral lesions are far more accurately mapped using traction magnetic resonance arthrography (MRA). Radiographs should serve merely as the baseline anatomic screening tool, while advanced magnetic resonance imaging modalities must become the gold standard for preoperative joint health evaluation and comparative cohort studies. Second, we need to reevaluate demographic dogma by looking beyond rigid demographic cutoffs. While age and sex are frequently cited as prognostic factors, their application is often contradictory. Recent literature suggests that female patients may actually demonstrate equivalent or superior survivorship compared with their male counterparts4. Similarly, advanced age alone should not universally preclude joint preservation, as carefully selected patients in their forties or even fifties can achieve excellent outcomes. Consequently, biological age, specifically the objective state of the articular cartilage, must supersede chronological age or sex as the primary prognostic variable. Third, the dynamic interplay of the spinopelvic unit remains a critical, yet underappreciated, frontier: As our young patients age, changes in pelvic tilt directly influence functional acetabular version, potentially inducing functional impingement or anterior dysplasia5. Evaluating this dynamic relationship is paramount for long-term success. Finally, the nuanced concepts of hip instability and complex torsional profiles demand meticulous attention: Overlooking abnormal femoral torsion or acetabular version is a proven catalyst for surgical failure6. While our grasp of these basic concepts is becoming more precise, we still must refine our indications regarding when, and exactly how much, correction of torsion or version is necessary to optimize hip biomechanics. Furthermore, we must discard the simplistic notion that instability is exclusively synonymous with frank dysplasia. Microinstability can plague patients who have only mild alterations in bone morphology, have impingement, or even have radiographically “normal” hip joints7. Therefore, an in-depth evaluation of the interplay between joint components will allow a better understanding of the complex etiology of instability, ultimately leading to improved surgical treatments. Current long-term results strongly support the surgical treatment of prearthritic hip pathologies. However, ongoing efforts to achieve a more precise understanding of each patient’s unique pathomechanics and joint health will be mandatory to reliably alter the natural history of hip osteoarthritis.