Emerging Technologies in Hip Arthroscopy
By: Jorge Chahla, M.D., Ph.D. and Luc M. Fortier, B.A.
In the last two decades, hip arthroscopy has become increasingly popular in treating various hip pathologies.1 As utilization of technology in different orthopaedic subspecialties continues to gain traction, hip arthroscopy is no different. Recent advancements in hip arthroscopy have focused on the application of technology to teach the next generation of surgeons the skills necessary to perform safe and effective hip arthroscopy as well as improve the accuracy and precision of hip arthroscopy procedures to provide better patient outcomes.2-6
Even though hip arthroscopy is rapidly expanding, its procedures are not as commonly performed as arthroscopic knee or shoulder procedures. This reality, coupled with decreases in Orthopaedic Resident caseloads and working hours, have made it difficult for some trainees and junior attendings to gain adequate experience in hip arthroscopy.6 The complex geometry of the hip joint and its thick soft-tissue envelope also make hip arthroscopy one with a particularly steep learning curve.7, 8 In response, a variety of virtual reality (VR) systems have been developed to provide trainees and novice surgeons a way to acquire the necessary skills to safely and effectively perform arthroscopic hip procedures.5, 6, 9-12 These developments are extremely promising and have the potential to shift the future of basic hip arthroscopy training. However, future efforts should attempt to introduce more advanced hip arthroscopy skills into VR training such as labral repair techniques and capsular management strategies.
Amid the upheaval of the COVID-19 pandemic, the shift towards virtual platforms born out of necessity has introduced new options for hip arthroscopy learning. Professional societies such as AANA and companies such as Avail Medsystems, Inc. have embraced how COVID-19 has reshaped the world by streaming live hip arthroscopy procedures online. These strategies offer a cost-effective and convenient way to reach a broad audience interested in sharing knowledge about surgical techniques and new products within hip arthroscopy.
Computer-assisted navigation technology has demonstrated its ability to provide more precise and accurate results for procedures such as joint reconstruction, anterior cruciate ligament reconstruction, trauma and spine surgery.3, 13-16 Recently, computer-assisted technology has also gained traction in hip arthroscopy due to the complex three-dimensional (3D) anatomy and limited visualization during these procedures. The benefit of computer-assisted navigation in hip arthroscopy is two-fold: preoperative planning and intraoperative assistance.
Preoperative planning for hip arthroscopy procedures addressing femoroacetabular impingement (FAI) traditionally rely heavily on calculating the alpha angle with two-dimensional (2D) static images. With computer software and virtual 3D reconstruction, Orthopaedic Surgeons can now dynamically manipulate models to localize areas of impingement, quantify planned resection and predict postoperative range of motion.3 There are a variety of different software programs that have been developed for this purpose, including HipMap and Hip Check (Stryker, United States), Mimics (Materialise, Belgium), Articulis (Clinical Graphics, Netherlands) and the DyonicsTM PLAN Hip Impingement Planning System (Smith+Nephew, United States).17-20 There is little doubt that these systems provide exciting opportunities for the future. However, additional comparative studies are required to truly ascertain any clinical benefits that these technologies provide over traditional methods.
Similarly, intraoperative computer-assisted navigation allows surgeons to more accurately reproduce the desired correction in real time. These systems rely on comparing preoperative 3D-computed tomography scans to intraoperative conditions while simultaneously tracking the movement of surgical instruments. Current high-level evidence has validated the effectiveness of these techniques.21, 22 The advantages of creating a more precise correction may reduce the risk of postoperative instability or reoperation. Studies also argue that these systems are useful in reducing the steep learning curve associated with novice surgeons in hip arthroscopy.23
Another exciting, emerging concept within hip arthroscopy includes robotic-assisted surgery. Recently introduced into clinical practice with joint reconstructions, robotic hip arthroscopy has yet to be used on live patients. Nonetheless, laboratory studies have demonstrated its feasibility and accuracy over freehand hip arthroscopy.24, 25 Robotic surgery certainly has the potential to revolutionize hip arthroscopy by allowing more complex and precise surgical procedures in a small working space.
Attention to the novel integration of technology and hip arthroscopy is paramount. The potential for this interplay to improve outcomes in hip arthroscopy is real, but there continues to exist significant room for growth and improvement. We must embrace these new technologies with an open mind to improve hip arthroscopy and push the boundaries of the best possible care we can provide our patients.
- Erickson, B.J., Cvetanovich, G.L., Frank, R.M., et al. "International Trends in Arthroscopic Hip Preservation Surgery - Are We Treating the Same Patient? Journal of Hip Preservation Surgery. 2015;2(1):28-41. doi:10.1093/jhps/hnv013
- Stražar, K. "Computer Assistance in Hip Preservation Surgery - Current Status and Introduction of Our System." International Orthopaedics. 2021;45(4):897-905. doi:10.1007/s00264-020-04788-3
- Nakano, N., Audenaert, E., Ranawat, A., Khanduja, V. "Review: Current Concepts in Computer-Assisted Hip Arthroscopy." The International Journal of Medical Robotics. 2018;14(6):e1929. doi:10.1002/rcs.1929
- Bauer, D.E., Wieser, K., Aichmair, A., Zingg, P.O., Dora, C., Rahm, S. "Validation of a Virtual Reality-Based Hip Arthroscopy Simulator." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2019;35(3):789-795. doi:10.1016/j.arthro.2018.10.131
- Bartlett, J.D., Lawrence, J.E., Khanduja, V. "Virtual Reality Hip Arthroscopy Simulator Demonstrates Sufficient Face Validity." Knee Surgery, Sports Traumatology, Arthroscopy. 2019;27(10):3162-3167. doi:10.1007/s00167-018-5038-8
- Bartlett, J.D., Lawrence, J.E., Yan, M., et al. "The Learning Curves of a Validated Virtual Reality Hip Arthroscopy Simulator." Archives of Orthopaedic and Trauma Surgery. 2020;140(6):761-767. doi:10.1007/s00402-020-03352-3
- Hoppe, D.J., de Sa, D., Simunovic, N., et al. "The Learning Curve for Hip Arthroscopy: A Systematic Review." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2014;30(3):389-97. doi:10.1016/j.arthro.2013.11.012
- Mehta, N., Chamberlin, P., Marx, R.G., et al. "Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship." American Journal of Sports Medicine. 2018;46(6):1284-1293. doi:10.1177/0363546517749219
- Gallagher, K., Bahadori, S., Antonis, J., Immins, T., Wainwright, T.W., Middleton, R. "Validation of the Hip Arthroscopy Module of the VirtaMed Virtual Reality Arthroscopy Trainer." Surgical Technology International. 2019;34:430-436.
- Khanduja, V., Lawrence, J.E., Audenaert, E. "Testing the Construct Validity of a Virtual Reality Hip Arthroscopy Simulator." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2017;33(3):566-571. doi:10.1016/j.arthro.2016.09.028
- Bishop, M.E., Ode, G.E., Hurwit, D.J., et al. "The Arthroscopic Surgery Skill Evaluation Tool Global Rating Scale is a Valid and Reliable Adjunct Measure of Performance on a Virtual Reality Simulator for Hip Arthroscopy." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2021;37(6):1856-1866. doi:10.1016/j.arthro.2021.01.046
- Harris, J.D. "Editorial Commentary: Virtual Reality Simulation Can Help Arthroscopic Hip Preservation Surgeons at All Levels of Training and Practice-This is How." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2021;37(6):1867-1871. doi:10.1016/j.arthro.2021.03.002
- Haaker, R.G., Tiedjen, K., Ottersbach, A., Rubenthaler, F., Stockheim, M., Stiehl, J.B. "Comparison of Conventional Versus Computer-Navigated Acetabular Component Insertion." The Journal of Arthroplasty. 2007;22(2):151-9. doi:10.1016/j.arth.2005.10.018
- Cobb, J., Henckel, J., Gomes, P., et al. "Hands-On Robotic Unicompartmental Knee Replacement: A Prospective, Randomised Controlled Study of the Acrobot System." Journal of Bone and Joint Surgery – British Volume. 2006;88(2):188-97. doi:10.1302/0301-620x.88b2.17220
- Voos, J.E., Musahl, V., Maak, T.G., Wickiewicz, T.L., Pearle, A.D. "Comparison of Tunnel Positions in Single-Bundle Anterior Cruciate Ligament Reconstructions Using Computer Navigation. Knee Surgery, Sports Traumatology, Arthroscopy. 2010;18(9):1282-9. doi:10.1007/s00167-010-1162-9
- Seon, J.K., Song, E.K. "Navigation-Assisted Less Invasive Total Knee Arthroplasty Compared With Conventional Total Knee Arthroplasty: A Randomized Prospective Trial." The Journal of Arthroplasty. 2006;21(6):777-82. doi:10.1016/j.arth.2005.08.024
- Tannast, M., Kubiak-Langer, M., Langlotz, F., Puls, M., Murphy, S.B., Siebenrock, K.A. "Noninvasive Three-Dimensional Assessment of Femoroacetabular Impingement." Journal of Orthopaedic Research. 2007;25(1):122-31. doi:10.1002/jor.20309
- Audenaert, E.A., Mahieu, P., Pattyn, C. "Three-Dimensional Assessment of Cam Engagement in Femoroacetabular Impingement." Arthroscopy: The Journal of Arthroscopic and Related Surgery. 2011;27(2):167-71. doi:10.1016/j.arthro.2010.06.031
- Röling, M.A., Visser, M.I., Oei, E.H., Pilot, P., Kleinrensink, G.J., Bloem, R.M. "A Quantitative Noninvasive Assessment of Femoroacetabular Impingement With CT-Based Dynamic Simulation – Cadaveric Validation Study. BMC Musculoskeletal Disorders. 2015;16:50. doi:10.1186/s12891-015-0504-7
- Milone, M.T., Bedi, A., Poultsides, L., et al. "Novel CT-Based Three-Dimensional Software Improves the Characterization of Cam Morphology." Clinical Orthopaedics and Relat Research®. 2013;471(8):2484-91. doi:10.1007/s11999-013-2809-x
- Van Houcke, J., Khanduja, V., Nakano, N., Krekel, P., Pattyn, C., Audenaert, E. "Accuracy of Navigated Cam Resection in Emoroacetabular Impingement: A Randomised Controlled Trial." The International Journal of Medical Robotics and Computer Assisted Surgery. 2017;13(4)doi:10.1002/rcs.1839
- Monahan, E., Shimada, K. "Computer-Aided Navigation for Arthroscopic Hip Surgery Using Encoder Linkages for Position Tracking." The International Journal of Medical Robotics and Computer Assisted Surgery. 2006;2(3):271-8. doi:10.1002/rcs.100
- Almoussa, S., Barton, C., Speirs, A.D., Gofton, W., Beaulé, P.E. "Computer-Assisted Correction of Cam-Type Femoroacetabular Impingement: A Sawbones Study." Journal of Bone and Joint Surgery – American Volume. 2011;93 Suppl 2:70-5. doi:10.2106/jbjs.J.01706
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