Analysis of Hip Preservation Questions on the Orthopaedic In-Training Examination Over the Past 20 Years.

Background: The orthopaedic in-training examination (OITE) is a 275-question test for orthopaedic residents administered annually. As the field of orthopaedics changes, the OITE evolves its content. The incidence of hip preservation-related procedures has increased substantially over the past decade; nonetheless, an analysis of the trends of hip preservation questions on the OITE has not yet been performed. Purpose/Hypothesis: The purpose of the study was to evaluate the number and type of questions on the OITE related to hip preservation to determine whether trends over time paralleled the increases in hip-related care in clinical practice. It was hypothesized that the frequency of hip preservation questions on the OITE would increase with time. Study Design: Cross-sectional study. Methods: Each OITE between 2002 and 2021 was reviewed for questions related to hip preservation. The types of questions included under "hip preservation" were those related to femoroacetabular impingement (FAI), athletic soft tissue injuries of the hip, acetabular labral tears, hip arthroscopy, and surgical management of adult hip dysplasia-excluding arthroplasty. Questions were quantified and categorized by topic, taxonomy level, associated imaging, and cited sources. Results: There were 30 hip preservation-related questions between 2002 and 2021. Of these, 77% occurred within the past 10 years. Also, 14 questions (47%) had associated images in the question stem-the most common being radiographs (n = 8 questions). The most commonly tested subcategories were FAI (n = 11 questions [37%]), athletic injuries (n = 7 questions [23%]), and anatomy (n = 7 questions [23%]). Over the last 10 years, 97.9% of citations were from journal articles-the most common being the Journal of the American Academy of Orthopaedic Surgeons, Clinical Orthopedics and Related Research, and the American Journal of Sports Medicine. Conclusion: The frequency of hip preservation-related questions on the OITE has increased with time, reflecting trends in clinical practice.

Trends in avascular necrosis and related arthroplasties in hospitalized patients with systemic lupus erythematosus and rheumatoid arthritis.

OBJECTIVE: Avascular necrosis (AVN) is a devastating complication often necessitating arthroplasty, particularly common in systemic lupus erythematosus (SLE). Limited research exists on arthroplasty trends since new steroid-sparing agents. We analyzed trends and characteristics associated with AVN and AVN-related arthroplasties among SLE and RA hospitalizations using two decades of data from the U.S. National Inpatient Sample (NIS). METHODS: This cross-sectional study used NIS (2000-2019) to identify hospitalized adults with SLE and RA, with or without AVN, using ICD codes. AVN was further grouped by arthroplasty status. Primary outcomes were AVN and AVN-related arthroplasty rates and time trends in SLE and RA. Baseline sociodemographics and comorbidities were compared. Analyses used STATA and Joinpoint regression to calculate annual percent change (APC). RESULTS: Overall, 42,728 (1.3 %) SLE and 43,600 (0.5 %) RA hospitalizations had concomitant AVN (SLE-AVN and RA-AVN). Of these, 16,724 (39 %) and 25,210 (58 %) underwent arthroplasties, respectively. RA-AVN increased (APC: 0.98*), with a decrease in arthroplasties (APC: -0.82*). In contrast, SLE-AVN initially increased with a breakpoint in 2011 (APC 2000-2011: 1.94* APC 2011-2019 -2.03), with declining arthroplasties (APC -2.03*). AVN hospitalizations consisted of individuals who were younger and of Black race; while arthroplasties were less likely in individuals of Black race or Medicaid coverage. CONCLUSION: We report a breakpoint in rising SLE-AVN after 2011, which may relate to newer steroid-sparing therapies (i.e., belimumab). AVN-associated arthroplasties decreased in SLE and RA. Fewer AVN-associated arthroplasties were noted for Black patients and those with Medicaid, indicating potential disparities. Further research should examine treatment differences impacting AVN and arthroplasty rates.

Depression Scores Decrease After Hip Arthroscopy for Femoroacetabular Impingement Syndrome.

Purpose: To evaluate clinical depression scores and functional outcomes following arthroscopic treatment of femoroacetabular impingement syndrome in patients with elevated preoperative depressive symptoms as defined by Patient-Reported Outcomes Measurement Information System for Depression (PROMIS-D). Methods: Patients with femoroacetabular impingement syndrome completed the PROMIS-D Computer Adaptive Test and additional patient-reported outcome (PRO) measures preoperatively and at the time of postoperative visits. Patients were categorized into preoperative clinically depressed (CD) and nonclinically depressed (NCD) groups based on preoperative PROMIS-D scores. Scores ≥55 correlate to mild clinical depression, and this cutoff was used to determine preoperative depression status. PROMIS-D scores and functional outcome scores were assessed at 6 months and a minimum of 1-year postoperatively. Results: In total, 100 patients were included with complete PROs at a minimum of 1-year follow-up. Of those included, 21 (21%) were categorized with preoperative CD. There were no differences in demographic or radiographic variables between the preoperative CD and NCD groups. At 6 months and 12 months postoperatively, the percentage of patients in the preoperative CD group with continued depression was 33.3% and 23.8%, respectively. Overall, 1-year change in PROMIS-D score for the CD group was -9.1 versus -0.8 in the NCD group (P = .001). There was no significant difference in rates of patients achieving patient acceptable symptom state between the preoperative CD and NCD groups. Conclusions: Patients with symptoms of preoperative CD, as defined by the PROMIS-D score, demonstrated significant improvement in depressive symptoms following hip arthroscopy. In addition, patients with CD preoperatively did not show decreased rates of achieving minimum clinically important difference or patient acceptable symptom state on postoperative PROs compared with patients with NCD. Level of Evidence: Level IV, therapeutic case series.

Comparison of MRI and arthroscopy findings for transitional zone cartilage damage in the acetabulum of the hip joint.

OBJECTIVE: To assess the performance of morphologic and hypointense signal changes on MRI to predict grades and types of acetabular cartilage damage in the chondrolabral transitional zone (TZ) of the hip identified at arthroscopy. MATERIALS AND METHODS: This retrospective single-center study reviewed conventional 3T MRI hip studies from individuals with symptomatic femoroacetabular impingement (FAI) and subsequent hip arthroscopy surgery within 6 months. Independent review was made by three radiologists for the presence of morphologic damage or a hypointense signal lesion in the TZ on MRI. Fleiss' kappa statistic was used to assess inter-reader agreement. The degree of TZ surfacing damage (modified Outerbridge grades 1-4) and presence of non-surfacing wave sign at arthroscopic surgery were collected. Relationship between sensitivity and lesion grade was examined. RESULTS: One hundred thirty-six MRI hip studies from 40 males and 74 females were included (mean age 28.5 years, age range 13-54 years). MRI morphologic lesions had a sensitivity of 64.9-71.6% and specificity of 48.4-67.7% for arthroscopic surfacing lesions, with greater sensitivity seen for higher grade lesions. Low sensitivity was seen for wave sign lesions (34.5-51.7%). MRI hypointense signal lesions had a sensitivity of 26.3-62% and specificity of 43.8-78.0% for any lesion. Inter-reader agreement was moderate for morphologic lesions (k = 0.601) and poor for hypointense signal lesions (k = 0.097). CONCLUSION: Morphologic cartilage damage in the TZ on MRI had moderate sensitivity for any cartilage lesion, better sensitivity for higher grade lesions, and poor sensitivity for wave sign lesions. The diagnostic value of hypointense signal lesions was uncertain.

Hip Manipulation Under Anesthesia for Post-Hip Arthroscopy Pericapsular Scarring: Indications and Techniques.

Hip arthroscopy has become an increasingly common procedure with expanding indications over the last several decades. With the increase in number of procedures performed a complication profile has emerged, although there is yet to be a formal classification system for complications. The most cited complications include lateral femoral cutaneous nerve neuropraxia, other sensory deficits, chondral or labral iatrogenic damage, superficial infection and deep vein thrombosis. One complication that has not yet been well documented in the literature is pericapsular scarring/adhesions resulting in decreased hip range of motion and function. If this complication is noted to persist after adequate impingement resection and a rigorous post-operative physical therapy regimen, the senior author has addressed this with a hip manipulation under anesthesia. Therefore, this techniques paper aims to describe pericapsular scarring as a post hip-arthroscopy condition which may cause pain and demonstrate our technique to address this diagnosis through hip manipulation under anesthesia.

Treatment of Coxa Profunda With Open Surgical Hip Dislocation, Rim Resection, Cam Resection, and Labral Reconstruction.

Coxa profunda presents a unique challenge in surgical treatment approach given global acetabular overcoverage. Arthroscopic treatment can be fraught with difficulty obtaining hip distraction for safe arthroscopic instrumentation, and limited arthroscopic access may prevent sufficient osseous resection of the excess acetabular rim. Although hip arthroscopy use has increased markedly over the past decades for all types of hip pathology, coxa profunda may represent one unique indication for surgical hip dislocation. This technique describes open surgical hip dislocation, rim resection, femoral osteoplasty, and labral reconstruction using anterior tibialis allograft for coxa profunda with combined-type femoroacetabular impingement syndrome and labral ossification.

Interpretation of Cartilage Damage at Routine Clinical MRI: How to Match Arthroscopic Findings.

This review is intended to aid in the interpretation of damage to the articular cartilage at routine clinical MRI to improve clinical management. Relevant facets of the histologic and biochemical characteristics and clinical management of cartilage are discussed, as is MRI physics. Characterization of damage to the articular cartilage with MRI demands a detailed understanding of the normal and damaged appearance of the osteochondral unit in the context of different sequence parameters. Understanding the location of the subchondral bone plate is key to determining the depth of the cartilage lesion. Defining the bone plate at MRI is challenging because of the anisotropic fibrous organization of articular cartilage, which is susceptible to the "magic angle" phenomenon and chemical shift artifacts at the interface with the fat-containing medullary cavity. These artifacts may cause overestimation of the thickness of the subchondral bone plate and, therefore, overestimation of the depth of a cartilage lesion. In areas of normal cartilage morphology, isolated hyperintense and hypointense lesions often represent degeneration of cartilage at arthroscopy. Changes in the subchondral bone marrow at MRI also increase the likelihood that cartilage damage will be visualized at arthroscopy, even when a morphologic lesion cannot be resolved, and larger subchondral lesions are associated with higher grades at arthroscopy. The clinical significance of other secondary features of cartilage damage are also reviewed, including osteophytes, intra-articular bodies, and synovitis. Online supplemental material is available for this article. Work of the U.S. Government published under an exclusive license with the RSNA.

Patients With Generalized Joint Hypermobility Have Thinner Superior Hip Capsules and Greater Hip Internal Rotation on Physical Examination.

Purpose: To compare preoperative hip range of motion (ROM), hip capsular thickness on magnetic resonance imaging (MRI), and bony morphology on radiographs and computed tomography (CT) between patients with and without joint hypermobility as measured by the Beighton Test score (BTS), with subanalysis based on sex and age. Methods: Consecutive patients who underwent hip arthroscopy for a diagnosis of femoroacetabular impingement syndrome with or without dysplasia were retrospectively reviewed. Patient BTS, hip ROM, demographics, surgical data, morphologic measures on radiographs and CT, and MRI findings including hip capsule thickness at various locations were compiled. Multiple statistical tests were performed, including multivariable linear or logistic regression models, while controlling for BTS, age, and sex. Results: In total, 99 patients were included with a mean age of 29 ± 9.9 years; 62 (62.6%), were female. Forty patients (40.4%) had a BTS ≥4. Female patients (P < .001) and younger patients (26.7 vs 30.9 years, P = .030) were more likely to have a BTS ≥4. Male patients had significantly thicker superior capsules (3.4 mm vs. 2.8 mm, P = .034). BTS was not associated with capsular thickness when controlling for sex. On CT, femoral version (18.9° vs 11.4°, P < .001), and McKibben index (37.8° vs. 28.2°, P < .001) were significantly greater in those with a BTS ≥4. Patients with a BTS ≥4 had more hip internal rotation at 90° of flexion (15.0° vs 10.0°, P < .001), when prone (30.0° vs 20.0°, P = .004), and in extension (10.0° vs. 5.0°, P < .001). Conclusions: All female patients, regardless of Beighton score, and all patients with a BTS ≥4 indicated for primary hip arthroscopy for femoroacetabular impingement syndrome with or without dysplasia were more likely to have thinner superior hip capsules on MRI and greater hip internal rotation on exam. Bony morphologic differences exist between sexes and between patients with and without hypermobility, likely contributing to differences in ROM. Level of Evidence: III, retrospective cohort study.

Current State of Research Gap-Years in Orthopedic Surgery Residency Applicants: Program Directors' Perspectives.

Background: The purpose of this study was to determine how orthopedic residency program directors (PDs) evaluate residency applicants who participated in a research gap-year (RGY). Methods: A 23 question electronically administered survey was created and emailed to all Accreditation Council for Graduate Medical Education (ACGME) orthopedic residency PDs for the 2020-21 application cycle. PDs were emailed directly if active contact information was identifiable. If not, program coordinators were emailed. The survey contained questions regarding the background information of programs and aimed at identifying how PDs view and evaluate residency applicants who participated in a RGY. Descriptive statistics for each question were performed. Results: Eighty-four (41.8%) of 201 PDs responded. Most respondent programs (N=62, 73.8%) identified as an academic center. The most common geographic region was the Midwest, N=33 (39.3%). Few programs (N=3, 3.8%) utilize a publication "cut-off" when screening residency applicants. When asked how many peer-reviewed publications were necessary to deem a RGY as "productive," responses ranged from 0-15 publications (median interquartile range 4.5 [3-5]). Forty-one (53.3%) PDs stated they would council medical students to take a RGY with USMLE Step 1 scores being the #1 factor guiding that advice. More PDs disagree than agree (N=35, 43.6%; vs N=22, 28.2%) that applicants who complete a RGY are more competitive applicants, and 35 PDs (45.5%) agree research experiences will become more important in resident selection as USMLE Step 1 transitions to Pass/Fail. Conclusion: Program directors have varying views on residency applicants who did a RGY. While few programs use a publication cutoff, the median number of publications deemed as being a "productive" RGY was approximately 5. Many PDs agree that research experiences will become more important as USMLE Step becomes Pass/Fail. This information can be useful for students interested in pursuing a RGY and for residency programs when evaluating residency applicants. Level of Evidence: IV.

Evidence-Based Musculoskeletal Care for Swimmers: A Critical Analysis Review.

¼: Swimming is a popular activity with numerous health benefits. ¼: Swimming involves complex biomechanical movements that, especially if performed incorrectly, can lead to musculoskeletal injuries. ¼: The shoulder is the most commonly affected joint, although lower-extremity and spine injuries have also been reported.

Dynamic Assessment of Femoroacetabular Impingement Syndrome Hips.

PURPOSE: The purpose of our study was to compare lower extremity rotational kinematics and kinetics (angles, torques, and powers) and hip muscle electromyography (EMG) activity between cam-type femoroacetabular impingement syndrome (FAIS) and age- and sex-matched controls during walking, fast walking, stair ascent, stair descent, and sit-to-stand. METHODS: This study included 10 males with unilateral FAIS and 10 control males with no FAIS. We measured kinematics, kinetics, and electromyographic signals during stair ascent/descent, sit-to-stand, self-selected walk, and fast walk. Peak signal differences between groups were compared with independent t-tests with statistical significance when P < .05. RESULTS: FAIS hips showed significant differences compared to controls, including increased hip flexion during walking (+4.9°, P = .048) and stair ascent (+7.8°, P =.003); diminished trunk rotation during stair ascent (-3.4°; P = .015), increased knee flexion during self-selected walking (+5.1°, P = .009), stair ascent (+7.4°, P = .001), and descent (+5.3°, P = .038); and increased knee valgus during fast walking (+4.7°, P = .038). gMed and MedHam showed significantly decreased activation in FAIS during walking (gMed: -12.9%, P = .002; MedHam: -7.4%, P = .028) and stair ascent (gMed: -16.7%, P = .036; MedHam: -13.0%, P = .041); decreased gMed activation during sit-to-stand (-8.8%, P = .004) and decreased MedHam activation during stair descent (-8.0%, P = .039). CONCLUSIONS: Three-dimensional motion analysis and EMG evaluation of functional kinematics and kinetics in subjects with symptomatic unilateral cam-type FAIS across a spectrum of provocative tasks demonstrated significant differences compared to controls in hip flexion, trunk rotation, knee flexion, and valgus. FAIS hips had significantly decreased gMed and MedHam activity. These findings may explain altered torso-pelvic, hip, and knee mechanics in FAIS patients and suggest that evaluation of FAIS should include the patient's hip, knee, and torso-pelvic relationships and muscle function. CLINICAL RELEVANCE: The clinical and functional manifestation of FAIS hip pathomechanics is not entirely understood, and previous literature to date has not clearly described the alterations in gait and functional movements seen in patients with cam-type FAIS. The current study used 3D motion analysis and EMG evaluation of functional kinematics and kinetics to identify a number of differences between FAIS and control hips, which help us better understand the lower extremity kinematics and kinetics and muscle activation in FAIS.

Next Steps: Advocating for Women in Orthopaedic Surgery.

Orthopaedic surgery is the least diverse of all medical specialties, by both sex and race. Diversity among orthopaedic trainees is the lowest in medicine, and growth in percentage representation is the lowest of all surgical subspecialties. Women comprise only 6% of orthopaedic surgeons and 16% of orthopaedic surgery trainees. This extreme lack of diversity in orthopaedics limits creative problem-solving and the potential of our profession. Women in orthopaedics encounter sexual harassment, overt discrimination, and implicit bias, which create barriers to training, career satisfaction, and success. Women are underrepresented in leadership positions, perpetuating the lack of diversity through poor visibility to potential candidates, which impedes recruitment. Correction will require a concerted effort, as acknowledged by the American Academy of Orthopaedic Surgeons leadership who included a goal and plan to increase diversity in the 2019 to 2023 Strategic Plan. Recommended initiatives include support for pipeline programs that increase diversity of the candidate pool; sexual harassment and implicit bias acknowledgement, education, and corrective action; and the active sponsorship of qualified, capable women by organizational leaders. To follow, women will lend insight from their diverse viewpoints to research questions, practice problems, and clinical conundrums of our specialty, augmenting the profession and improving patient outcomes.

Do intra-articular knee injuries detected by preoperative MRI affect the clinical management of extensor mechanism ruptures?

OBJECTIVES: We sought to determine the prevalence of intra-articular findings at the time of extensor mechanism injury that required subsequent surgical intervention. DESIGN: Retrospective cohort study. SETTING: Level 1 academic trauma center. PATIENTS/PARTICIPANTS: Sixty-seven knees in 66 nonconsecutive patients (mean age 53.6 years, 95.6% male) with extensor mechanism injury and preoperative magnetic resonance imaging (MRI) before undergoing open primary surgical repair. MAIN OUTCOME MEASUREMENTS: Patellar or quadriceps tendon rupture, high or low injury energy level, and age above or below 45 years were used to stratify patients. The primary outcome was additional surgery for intra-articular injury. Demographics, comorbidities, mechanism and location of injury, and internal derangements based on MRI findings were also collected. RESULTS: Fifty-one knees (76.1%) had quadriceps tendon injury, 13 knees (19.4%) had patellar tendon injury, and 3 knees (4.6%) had both. Thirty-four knees (50.7%) had intra-articular pathology and 3 (4.5%) required additional surgery, including 1 knee (7.7%) with patellar tendon injury and 2 knees (3.9%) with quadriceps tendon injury. Patellar tendon injuries were more commonly associated with cruciate ligament injury (P < .01) and occurred in younger patients (P < .001) than quadriceps tendon injury. CONCLUSIONS: 50.7% of cases with extensor mechanism injury had intra-articular pathology but only 4.5% required additional surgery. The results of our study suggest that preoperative MRI is unlikely to be of significant clinical utility in most extensor mechanism injuries but should be considered in cases of patellar tendon rupture in younger patients where the incidence of concomitant cruciate ligament injury is higher. LEVEL OF EVIDENCE: Diagnostic Level III.

Incidence of Research Gap Years in Orthopaedic Residency Applicants: The New Standard?

INTRODUCTION: The purpose of this study was to (1) determine the incidence of a research gap year (RGY) in orthopaedic residency applicants at a single institution over a seven-year span; (2) compare applicant characteristics between applicants who did a RGY with those who did not, and (3) report variables associated with match success for RGY applicants. METHODS: Applicants who reported taking a year out from medical school to pursue research on their Electronic Residency Application Service to a single institution from 2014 to 2015 through 2020 to 2021 were reviewed. RESULTS: A strong positive correlation was noted between the percentage of applicants who participated in a RGY and time (Pearson correlation: r = 0.945 [95% confidence interval (CI), 0.666-0.992], P = 0.001). Over the study period, 11% of applicants had done a RGY, most commonly after their third year of medical school (82.7%). Most RGY applicants matched orthopaedics (72.8%) and 19.4% matched at the same institution they did their RGY. CONCLUSION: The percentage of RGY applicants to the study institution nearly doubled between 2014 to 2015 and 2020 to 2021. RGY applicants had a higher match rate than nationally published match rates. Further study is needed on a national level.

Combined Hip Arthroscopy and Periacetabular Osteotomy (PAO): Technical Focus on Arthroscopically Elevating the Iliocapsularis and Performing the Open PAO.

In this Technical Note, we discuss the combined hip arthroscopy and periacetabular osteotomy (PAO) for the treatment of symptomatic hip dysplasia, with a focus on the technique we use for the PAO. We identify modifications that can be made during the arthroscopic portion of the procedure to assist in the PAO dissection, including arthroscopic capsular closure and arthroscopic elevation of the iliocapsularis muscle off the capsule, which allows for expedited open exposure during the PAO.

Interrater Reliability of the Prone Apprehension Relocation Test.

BACKGROUND: The Prone Apprehension Relocation Test (PART) augments existing radiographic measures and clinical provocative maneuvers in diagnosing hip instability. One measure of the potential clinical utility of the PART depends on the reproducibility of test results by evaluating providers including physicians, licensed athletic trainers, and physical therapists. PURPOSE: To determine the interrater reliability of the PART among health care providers. STUDY DESIGN: Cohort study (diagnosis); Level of evidence, 3. METHODS: We retrospectively identified patients in our institution's hip preservation registry who presented between September 2017 and June 2019 for evaluation of hip pain. Patients included in the study had the PART performed by a single physician as well as 1 of 12 physician extenders (a licensed athletic trainer or a physical therapist). The providers were blinded to the findings of the other examining professional. Interrater reliability was assessed using the Cohen κ (≥0.75 was considered excellent; between 0.75 and 0.40, moderate; and ≤0.40, poor). RESULTS: A total of 96 patients (190 hips) were included in this study (61 women and 35 men, average age 32 ± 12.1 years). A total of 23 hips had a positive PART from both examiners. Interrater reliability was excellent between health care professionals for the PART when evaluating the right hip (κ = 0.80), left hip (κ = 0.82), and when combining the results for left and right (κ = 0.81). A subanalysis of patients with a positive PART from both raters demonstrated that 19 of the 23 hips had a lateral center-edge angle >25°. CONCLUSION: Our study demonstrated excellent interrater reliability of the PART, supporting its use in the physical evaluation of painful hips.

Excision of Heterotopic Ossification around the Hip: Arthroscopic and Open Techniques.

Heterotopic ossification (HO) can occur as a complication of various pathologies affecting the hip including trauma, tendon avulsions, chronic injury, spinal cord injury, and soft-tissue disruption caused by surgery. When HO is present alongside intra-articular hip pathology such as femoroacetabular impingement syndrome (FAIS) or labral pathology, consideration should be made to combine the surgical excision of the HO with the FAIS decompression or labral repair if the location and size of the HO is appropriate for arthroscopic excision. Often times, the HO is located in such a position that any central compartment work can be completed before turning to the HO excision. If an open approach is required, the modified Gibson approach can be used for lateral hip access, whereas the Smith-Petersen approach provides anterior hip access. In this Technical Note we discuss arthroscopic techniques for excision of HO in the setting of concomitant FAIS, with discussion of when HO excision occurs in relation to cam decompression and labral repair, and mention tips on how to approach HO excision through an open approach.

Editorial Commentary: Hip Arthroscopy Evolution and Causes of Failure.

Hip arthroscopy use has grown as a result of expanding indications; improved imaging including higher resolution magnetic resonance imaging with stronger magnetic fields and the advent of 3-dimensional computed tomography revealing the nuances of hip joint morphology; increased specialized training; improvements in instruments and implants; a record of successful outcomes; and increased understanding of microinstability, focal acetabular undercoverage or occult dysplasia, indications for labral reconstruction and capsular plication, and, most of all, femoroacetabular impingement syndrome, the leading diagnosis for which hip arthroscopy is performed, in the orthopaedic community as well as the general medical and athletic communities. We now know that labral repair results in better outcomes than labral debridement, and evidence suggests that capsule closure leads to better long-term success. Osteoarthritis and its correlate, advanced age, result in inferior survivorship after hip arthroscopy, which is unsurprising; hip preservation surgery is not designed to treat irreparable cartilage damage. Association of female sex with hip arthroscopy failure requires additional investigation. More females undergo hip arthroscopy than males, and females initially present with greater disability. Females tend to have smaller alpha angles, greater femoral and acetabular anteversion, and lower center edge angles than males, consistent with increased prevalence of hip dysplasia. Thus surgeons indicating females for hip arthroscopy should be aware of atypical locations of cam lesions, borderline dysplasia, or ligamentous laxity, all of which must be appropriately respected at the time of surgery. With all of the improvements we have made in techniques, patient diagnosis and surgical indications, and our overall understanding of complex anatomy and a technically challenging surgery, we can speculate that our long-term survivorship will only improve. I await with interest the long-term outcomes we will see 10 years from today, with the addition of insight from patient-reported outcome measures to answer these questions with greater certainty.