There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article:
Despite being one of the most common orthopaedic
operations, it is still not known how many arthroscopies of the knee
must be performed during training in order to develop the skills
required to become a Consultant. A total of 54 subjects were divided
into five groups according to clinical experience: Novices (n =
10), Junior trainees (n = 10), Registrars (n = 18), Fellows (n =
10) and Consultants (n = 6). After viewing an instructional presentation,
each subject performed a simple diagnostic arthroscopy of the knee
on a simulator with visualisation and probing of ten anatomical
landmarks. Performance was assessed using a validated global rating
scale (GRS). Comparisons were made against clinical experience measured
by the number of arthroscopies which had been undertaken, and ROC
curve analysis was used to determine the number of procedures needed
to perform at the level of the Consultants. There were marked differences between the groups. There was significant
improvement in performance with increasing experience (p <
0.05). ROC curve analysis identified that approximately 170 procedures
were required to achieve the level of skills of a Consultant. We suggest that this approach to identify what represents the
level of surgical skills of a Consultant should be used more widely
so that standards of training are maintained through the development
of an evidenced-based curriculum. Cite this article:
Randomised controlled trials represent the gold standard in the evaluation of outcome of treatment. They are needed because differences between treatment effects have been minimised and observational studies may give a biased estimation of the outcome. However, conducting this kind of trial is challenging. Several methodological issues, including patient or surgeon preference, blinding, surgical standardisation, as well as external validity, have to be addressed in order to lower the risk of bias. Specific tools have been developed in order to take into account the specificity of evaluation of the literature on non-pharmacological intervention. A better knowledge of methodological issues will allow the orthopaedic surgeon to conduct more appropriate studies and to better appraise the limits of his intervention.
