Editorial Commentary: Indications for Performing Hip Arthroscopy in Addition to Periacetabular Osteotomy for the Treatment of Developmental Dysplasia of the Hip Require Clarification.

The combination of hip arthroscopy and periacetabular osteotomy (PAO) has been proven safe and effective for addressing symptoms in patients with developmental dysplasia of the hip. As not every patient with dysplasia will require a hip arthroscopy to obtain desired clinical improvement in the setting of PAO, a challenge is identifying which patients require adjacent procedures (either via arthroscopic or open) to fully treat their hip pathology. Even though labral repair is the most reported arthroscopic procedure in cases of hip dysplasia, I would suggest that labral treatment is the least likely helpful component of hip arthroscopy in these cases. Not all patients with hip dysplasia will have restoration of their suction seal after arthroscopic repair or debridement of the labrum. On the basis of numerous studies demonstrating the effectiveness of PAO for hip dysplasia, labral pathology has unknown importance for either mechanical stability or for the long-term survivorship of the dysplastic hip and thus must be examined instead as a significant pain generator. Reorientation of the labrum out of the zone of injury, and/or desensitization of the labrum during labral stabilization, may alleviate pain generated from labral pathology in the setting of PAO for dysplasia. I find hip arthroscopy to be most helpful as a tool to assess articular cartilage and address femoroacetabular impingement in the most common forms of subspine or true femoral cam morphology, when present. One may argue that the best evaluation of femoroacetabular impingement only exists after PAO correction is achieved. In cases in which I am concerned about iatrogenic impingement from reorientation, particularly in the subspine area, I have intentionally delayed capsule closure to be able to assess and address residual impingement after PAO. Despite the fact that combining hip arthroscopy and PAO in a single stage is safe, we should approach hip arthroscopy and capsulotomy with trepidation, as capsular adhesions, iatrogenic articular cartilage damage, and disruption of capsular integrity are all risks best avoided if capsule violation is not necessary. Clearer definitions for labral pathology and indications for repair or debridement are required.