this lecture for the Arthroscopy Association of North America Hip Arthroscopy Toolkit. The title today is Hip Arthroscopy Contraindications. My disclosures are available at AOS.org and I want to also make the unique disclosure that appropriate candidates for surgery are determined in specific clinical settings and as part of an overall plan of care established through shared decision making between individual patients and their designated care teams with informed patient consent. So all of the discussion we have about contraindications can be really considered relative contraindications and not a criticism of decision for individual care. By way of introduction, hip arthroscopy and endoscopy procedures are safer than ever with modern equipment and over a decade of internationally applied techniques that really give us courage to move forward. Modern outcomes research, however, using patient reported outcome measures in particular in registry format, they may fail to adequately identify differences between surgical interventions and which we think is very important due to the common ability of experts to avoid poor candidates seemingly make all things seem like they work. But really attention to the whole surgical encounter from initial office visit all the way to recovery is mandatory to achieve the best modern outcomes. Some evidence-based medicine to consider, although there's many different publications available at this point, Ross, Larson and Betty gave a wonderful overview of what they thought were the indications for hip arthroscopy and there's a small footnote on contraindications and this is a worthwhile document to read. Some summary findings, some level five contraindications after several experiences over the years in doing this procedure. Hip arthroscopy, however, is not all one procedural risk. There are risks that are specific to each type of hip arthroscopic technique. The central compartment where traction, bone constraint and access, capsule management become the main issues. Peripheral compartment where capsule management, the skills at reshaping the femur safely and with respect to soft tissues become considerations. The peritrocanteric space where fluid management down into the thigh, into the abdomen, tended to bone repair and suture management techniques more common in rotator cuff surgeries and grafting procedures are all part of the game. And the posterior deep gluteal space, perhaps the most difficult of all, where fluid management and abdominal extravasation, patient positioning, nerve challenges all may run into play in this particular area. So hip arthroscopy no longer means just one thing. For purposes of organizing these concepts, I'd like you to consider that operations may be contraindicated in the area of hip arthroscopy and endoscopy for four basic reasons. For medical reasons, for structural reasons, for technical reasons and for social reasons. I would suggest that all of these are important and they can all sneak up to bite you if you're not careful. Of course, medical safety and relative contraindications to surgery need to be considered. Starting with mental health factors, we've seen that catastrophization, poor resiliency, secondary gain issues and chronic pain or opioid dependency inside the subjective envelope of our patients preoperatively may well be a good idea to consider as a relative contraindication for your standard procedures or even for the procedure itself. Of course, cardiopulmonary and systemic disease must be considered. Are they suitable for general anesthesia? Are they suitable for neuromuscular blockade? If you're not doing general and you're doing regional, do they have any conditions that make those less safe or non-indicated procedures? Concomitant spinal, autoimmune or neuroendocrine axis disorders that may make the best arthroscopy not work to solve the patient's actual problem must be considered as a relative contraindication. And finally, I think it should be stated in this current modern climate that if you have an infected total joint arthroplasty or a seriously mechanically compromised total joint arthroplasty, this is a relative medical contraindication to surgical intervention endoscopically. Understand that the structural and developmental aspects of what we correct are the hallmarks of hip preservation surgery, not only correcting the soft tissue damage, but also potentially the mechanical and the structural osseous developmental condition that may have led to that damage. When we have severe skeletal deformity where there is not enough acetabular bone or where the femoral deformity is so severe that it requires reorientation globally in any of the number of the three-dimensional plane angles that this can be done, this is a contraindication to a standalone arthroscopic hip surgery. Tonus 3 osteoarthritis or severe osteoarthritis defined in most papers by less than two millimeters of joint space on a sore seal measurement on weight-bearing views is significantly correlated with poor outcome and conversion and should be considered a contraindication to arthroscopic surgery. This is a candidate rather for total hip arthroplasty. And then rarely, acetabular fracture or trauma settings can provide a compromised bony structure for the fluid required for arthroscopic surgery, and this must be considered a relative contraindication from that structural or developmental perspective for hip arthroscopic procedures. What about technical? I think that the technical approach is something that is common to most arthroscopic surgeons, so if this is part of your toolkit at Arthroscopy Association of North America, you're very familiar with needing to be prepared, but just make sure that we suffice to say that lack of available equipment is a contraindication to this operation. We need hip-specific access instrumentation, a modern hip distraction apparatus, and appropriately the length and scaled instruments for the deployment target tissue of the acetabulum or the target tissue that you're intending to work with. If you do not have these instruments, you're going to be outside the modern standards and you're going to need to move towards a contraindication approach. Or the lack of appropriate human resources, where the OR team is unfamiliar with the procedural steps, with the wrist itself, makes a very dangerous situation for the patient, is not ready for arthroscopic surgery. Anesthesia and the recovery room also need to be aware of the very specific risks associated with hip arthroscopic surgery, in particular in the intra-abdominal, extravasation of fluid, abdominal compartment syndromes, neurological disorders, and or other challenges associated with traction. And patient-specific technical challenges, like the size of the patient, the severity of the surrounding deformity to the hip acetabular or femoral head articulation, like femoral malformations and or overhanging iliac spine, different types of examples that might make access exceptionally difficult, if not impossible, must be considered. And depending upon the surgical experience and skill that you've acquired and you feel comfortable bringing a patient safely through, you may decide that certain cases are contraindications, maybe not in all hands, but in where you are at that time with your given team and with your given patient-specific factors that are present. And these can't be overstated as important and reasonable contraindications for offering the surgery in your hands. The social envelope is one that I think is missed most frequently when we're trying to start into the hip arthroscopic realm. I think most of us are appreciating the need to be technically proficient. There are many Arthroscopy Association North America labs, mobile labs, and other industry partner labs that are available to help build the technical. But what about the actual mechanics of getting that patient into the operating room? First of all, they've got to have family and caregiver support for the recovery for this procedure. That should be drilled preoperatively, monitored throughout the early postoperative course. And access to postoperative rehabilitation team needs to be identified before the operation. If it cannot be done, this particular operation will have punitive results for the surgeon and the patient. They need to be making time away from their work, home, schools, and sports for recovery for your surgery. If they're not doing this, then the inappropriate belief that the surgery is minimally invasive and they can go right back to their work and life may create for a poor outcome. And I believe there's another relative contraindication for the readiness for arthroscopic hip surgery. A poor recovery environment is another area that we need to really take a look at. If there's pressure to surgery, and this could happen even in professional team settings, if there is poor domestic safety, these are things that need to be really evaluated on a case-by-case basis to make sure that the patient who will be in a compromised position in a sensitive area about the hip and groin, to be sure that they have a good recovery environment to have attention to care and detail. And finally, you've got to have in place a referral network for if and when things are challenging. There should be allied specialists that are available quickly to you that are in fields like obstetrics, gynecology, urology, general surgery, psychiatry, rheumatology, allergy immunology, and these other allied fields that help us when and if spinal disorders, neuroendocrine disorders, or other medical disorders may prevent the patient from fully gaining the benefit of arthroscopic surgery, and you don't give them a sense of abandonment as they're still struggling postoperatively. So, that's a postoperative consideration that might actually contribute to a preoperative contraindication to a well-performed surgery. Just some nuance here. There is such a thing as diagnostic-first operative arthroscopy in 2025. Attending to the patient may include a plan to perform a safe arthroscopic central compartment procedure or even peripheral procedure to identify and document pathology in advance of more advanced joint preservation surgery, periprosthetic surgery, or sub-tissue extra-articular surgery. If this is a planned arthroscopy as part of a global expert team, it may take certain conditions that may lie in a relative contraindication area and turn that into a well-indicated arthroscopy. A specific example might be when we have dysplasia and we have the quest for multiple teams around the globe to perform first-turn arthroscopy to assess the available bone stock as well as the articular cartilage on the femoral head and the acetabulum in the intended reorientation zone. This is something that is not treating dysplasia with arthroscopy, but rather identifying appropriate candidates for an advanced procedure. We have to respect technical, medical, and social concerns, but when we're dealing with this, if a diagnostic arthroscopy may put that person into a better category of candidacy for a larger procedure, this may make into a relative contraindication, turn into something that may be acceptable with appropriate informed consent. So, in conclusion, hip arthroscopy requires a comprehensive understanding of patient, surgeon, and care setting for proper patient selection, and I think with attention to medical, structural, and technical, along with social aspects of care, it's possible to succeed. When we're dealing with arthroscopic surgery, I think if we can really put into our final Pearl Toolkit, remembering that with hip preservation techniques through arthroscopic surgery in modern times, the most that we can do is try to correct excessive bone that has grown or has developed in the wrong place and do that without creating a bony instability or sub-tissue defect from our surgery. If, in fact, the pathology that we're attempting to tackle requires reoriented bone or the addition of more support bone, then right out of the gate, we need to be not asking ourselves, is arthroscopy indicated, but we need to be asking ourselves, why isn't arthroscopy already out of the picture? So, hopefully, these concepts help to unify a process for you to consider and when sort of to say no as opposed to when to say when. Thank you for your time and attention to some photographs of the many friends, a few of the many friends at the Anorthopedic Learning Center over the years, and if you ever find yourselves in Washington, D.C., come on in and we'll be happy to learn together.

hip arthroscopy

contraindications

shared decision-making

patient outcomes

diagnostic arthroscopy