Letters to the Editor
Regarding “Global Discrepancies in the Diagnosis, Surgical Management, and Investigation of Femoroacetabular Impingement” To the Editor: We have read, with interest, the article by Yeung et al.1 entitled “Global Discrepancies in the Diagnosis, Surgical Management, and Investigation of Femoroacetabular Impingement.” The authors describe differences in surgical management of femoroacetabular impingement (FAI) worldwide. When analyzing the distribution of studies regarding region, they found 52 studies from North America, 44 studies from Europe, 6 studies from Oceania, 3 studies from Asia, and no studies from South America. The electronic databases searched in this article were MEDLINE, EMBASE, and the Cochrane Library. LILACS is a scientific database that comprises scientific and technical literature of Latin America and the Caribbean. It includes 27 countries, 887 journals, and more than 500,000 articles.2 In a quick search in LILACS, we found articles from Brazil,3 Argentina,4 and Chile,5 among others on the topic of FAI and hip arthroscopy. Moreover, searching MEDLINE, we found a paper from Brazil on the same topic,6 published after the search performed by Yeung et al. South America is indeed a developing region; however, orthopaedic surgery and arthroscopy are traditional fields of research in this region. As pointed out in Yeung’s paper, publishing papers in a different language can be difficult for a variety of reasons, which is definitely one explanation for the lack of South American papers regarding FAI. Perhaps other arthroscopic fields would encounter similar disparities in regional distribution. We acknowledge that South America should engage in publishing in various mainstream orthopaedic journals. Specifically, our physician group is engaged in this endeavor. In our hospital, there is ongoing FAI research, with the goal to publish this research in a major orthopaedic journal. We are confident other groups in South America are also focusing on this same goal. It is beneficial for the scientific community as a whole that valuable knowledge is as accessible as possible. MEDLINE, EMBASE, and the Cochrane Library should embrace an international effort to include developing and noneEnglish-speaking countries in their database journals. Such an effort could facilitate increased distribution and accessibility of South American scientific studies. Although Yeung et al.’s paper did not find any
South American studies reporting on FAI, the continent has pertinent research in this field. This shows the need for South America to focus on publishing studies in journals that reach a wider audience, as well as database journals such as MEDLINE and EMBASE, to be more inclusive of studies from developing and noneEnglish-speaking countries. With both of these efforts made, there will be a more accurate representation of the current literature, greatly benefiting the scientific community.
Acknowledgment The authors thank Lauren Matheny for kindly reviewing the manuscript in English.
Leandro Ejnisman, M.D. Helder de Souza Miyahara, M.D. Henrique Melo de Campos Gurgel, M.D., Ph.D. José Ricardo Negreiros Vicente, M.D., Ph.D. Alberto Tesconi Croci, M.D., Ph.D. São Paulo, Brazil Note: The authors report that they have no conflicts of interest in the authorship and publication of this letter. Editors’ Note: We enthusiastically support our Brazilian colleagues as we note that “English is now used almost exclusively as the language of science.”1 We encourage our South American colleagues to publish in English, despite the difficulty. 1. Drubin DG, Kellogg DR. English as the universal language of science: Opportunities and challenges. Mol Biol Cell 2012;28:1399. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.09.006
References 1. Yeung M, Khan M, Schreiber VM, et al. Global discrepancies in the diagnosis, surgical management, and investigation of femoroacetabular impingement. Arthroscopy 2015;31:1625-1633. 2. BIREME e PAHO e WHO: Latin-American and Caribbean Center on Health Sciences Information. Virtual Health
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 1 (January), 2015: pp 7-11
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LETTERS TO THE EDITOR Library. LILACS. Available at: http://lilacs.bvsalud.org/en. Accessed October 2, 2014. Ejnisman L, Lipai RR, Cabrita HB, et al. Arthroscopic treatment of hip pathology in 35 athletes. Rev Bras Med 2011;68:6-10. Comba F, Buttaro M, Piccaluga F. Arthroscopic treatment of cam type femoroacetabular impingement of the hip: Surgical technique and initial results. Artrosc (B Aires) 2010;17:43-49. Mardones R, Tomic A, Vega R, Orrego M. Arthroscopic treatment of femoroacetabular impingement: Surgical technique and early results. Rev Argent Artroscop 2006;13:90-101. Polesello GC, Lima FR, Guimaraes RP, Ricioli W, Queiroz MC. Arthroscopic treatment of femoroacetabular impingement: Minimum five-year follow-up. Hip Int 2014;24:381-386.
Regarding “Anterior Hip Dislocation 5 Months After Hip Arthroscopy”
To the Editor: I read with great interest the article “Anterior Hip Dislocation 5 Months After Hip Arthroscopy” by Austin et al.1 I would like to thank the authors for such an informative article. Being an amateur hip arthroscopy surgeon, it was an eye opener. I would be much obliged if the authors could answer a few questions I have. 1. How much of the capsule should be released, considering that we have to do the interportal capsular release and also the femoral neck capsular release since the authors stressed the importance of proper management of capsular release? Although we suture the capsule back before the skin closure, there is no proper information regarding the amount of capsular release.2 2. Since clinicoradiologically, the lesion was a cam lesion, can the excessive amount of femoral neck osteoplasty or resection be a cause of the patient’s anterior dislocation?3,4 3. Considering a female patient, what was her preoperative Beighton score? What are the chances that excessive ligament laxity might have been missed that would have been aggravated by the capsular release and femoral neck resection? I believe laxity can be one of the causes, considering the authors did not observe a capsular tear in the follow-up MRI. We close the capsule regularly in all our cases and believe it should be done without fail. Sarthak Patnaik, M.S.Ortho, F.S.S.I.S.A., F.A.S.M. Santander, Spain
Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.11.002
References 1. Austin DC, Horneff JG, Kelly JD. Anterior dislocation 5 months after hip arthroscopy. Arthroscopy 2014;30:1380-1382. 2. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br 2007;89:971-976. 3. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88: 925-935. 4. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404.
Author’s Reply To the Editor: I appreciate the inquiries by Dr. Patnaik and will attempt to answer them in sequence. 1. Regarding the volume of capsular release: In my opinion, the amount of capsular release should be just enough (but not more) to gain access to the femoral neck. The use of distraction portals and sutures can mitigate the need for complete iliofemoral ligament release. 2. Regarding cam resection as a source of instability: Theoretically cam resection does increase capsular laxity because it reduces the volume of intraarticular bone. Although excessive anterior neck resection can potentiate posterior subluxation in high hip flexion, I am not aware of any studies directly correlating bony cam resection alone with anterior instability. In our patient, I suspect the principle cause was anterior capsular laxity. 3. Regarding the issue of missed preoperative anterior instability: This question underscores the importance of more frequently recognized subtle anterior instability lesions of the hip, especially in female patients with ligamentous laxity. However, our patient did not display the characteristic straight anterior chondral wear pattern or direct anterior labral changes one would expect with anterior instability. Our patient showed the characteristic “wave sign” seen in cam impingement. I am grateful for Dr Patnaik’s questions and comments. Hip arthroscopists must be increasingly mindful of the role of instability, whether unrecognized or, as in this case, iatrogenic. More recent data suggest that better overall outcomes may be achieved with routine capsular closure.1
Regarding “Global Discrepancies in the Diagnosis, Surgical Management, and Investigation of Femoroacetabular Impingement” To the Editor: We have read, with interest, the article by Yeung et al.1 entitled “Global Discrepancies in the Diagnosis, Surgical Management, and Investigation of Femoroacetabular Impingement.” The authors describe differences in surgical management of femoroacetabular impingement (FAI) worldwide. When analyzing the distribution of studies regarding region, they found 52 studies from North America, 44 studies from Europe, 6 studies from Oceania, 3 studies from Asia, and no studies from South America. The electronic databases searched in this article were MEDLINE, EMBASE, and the Cochrane Library. LILACS is a scientific database that comprises scientific and technical literature of Latin America and the Caribbean. It includes 27 countries, 887 journals, and more than 500,000 articles.2 In a quick search in LILACS, we found articles from Brazil,3 Argentina,4 and Chile,5 among others on the topic of FAI and hip arthroscopy. Moreover, searching MEDLINE, we found a paper from Brazil on the same topic,6 published after the search performed by Yeung et al. South America is indeed a developing region; however, orthopaedic surgery and arthroscopy are traditional fields of research in this region. As pointed out in Yeung’s paper, publishing papers in a different language can be difficult for a variety of reasons, which is definitely one explanation for the lack of South American papers regarding FAI. Perhaps other arthroscopic fields would encounter similar disparities in regional distribution. We acknowledge that South America should engage in publishing in various mainstream orthopaedic journals. Specifically, our physician group is engaged in this endeavor. In our hospital, there is ongoing FAI research, with the goal to publish this research in a major orthopaedic journal. We are confident other groups in South America are also focusing on this same goal. It is beneficial for the scientific community as a whole that valuable knowledge is as accessible as possible. MEDLINE, EMBASE, and the Cochrane Library should embrace an international effort to include developing and noneEnglish-speaking countries in their database journals. Such an effort could facilitate increased distribution and accessibility of South American scientific studies. Although Yeung et al.’s paper did not find any
South American studies reporting on FAI, the continent has pertinent research in this field. This shows the need for South America to focus on publishing studies in journals that reach a wider audience, as well as database journals such as MEDLINE and EMBASE, to be more inclusive of studies from developing and noneEnglish-speaking countries. With both of these efforts made, there will be a more accurate representation of the current literature, greatly benefiting the scientific community.
Acknowledgment The authors thank Lauren Matheny for kindly reviewing the manuscript in English.
Leandro Ejnisman, M.D. Helder de Souza Miyahara, M.D. Henrique Melo de Campos Gurgel, M.D., Ph.D. José Ricardo Negreiros Vicente, M.D., Ph.D. Alberto Tesconi Croci, M.D., Ph.D. São Paulo, Brazil Note: The authors report that they have no conflicts of interest in the authorship and publication of this letter. Editors’ Note: We enthusiastically support our Brazilian colleagues as we note that “English is now used almost exclusively as the language of science.”1 We encourage our South American colleagues to publish in English, despite the difficulty. 1. Drubin DG, Kellogg DR. English as the universal language of science: Opportunities and challenges. Mol Biol Cell 2012;28:1399. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.09.006
References 1. Yeung M, Khan M, Schreiber VM, et al. Global discrepancies in the diagnosis, surgical management, and investigation of femoroacetabular impingement. Arthroscopy 2015;31:1625-1633. 2. BIREME e PAHO e WHO: Latin-American and Caribbean Center on Health Sciences Information. Virtual Health
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 31, No 1 (January), 2015: pp 7-11
7
8
3.
4.
5.
6.
LETTERS TO THE EDITOR Library. LILACS. Available at: http://lilacs.bvsalud.org/en. Accessed October 2, 2014. Ejnisman L, Lipai RR, Cabrita HB, et al. Arthroscopic treatment of hip pathology in 35 athletes. Rev Bras Med 2011;68:6-10. Comba F, Buttaro M, Piccaluga F. Arthroscopic treatment of cam type femoroacetabular impingement of the hip: Surgical technique and initial results. Artrosc (B Aires) 2010;17:43-49. Mardones R, Tomic A, Vega R, Orrego M. Arthroscopic treatment of femoroacetabular impingement: Surgical technique and early results. Rev Argent Artroscop 2006;13:90-101. Polesello GC, Lima FR, Guimaraes RP, Ricioli W, Queiroz MC. Arthroscopic treatment of femoroacetabular impingement: Minimum five-year follow-up. Hip Int 2014;24:381-386.
Regarding “Anterior Hip Dislocation 5 Months After Hip Arthroscopy”
To the Editor: I read with great interest the article “Anterior Hip Dislocation 5 Months After Hip Arthroscopy” by Austin et al.1 I would like to thank the authors for such an informative article. Being an amateur hip arthroscopy surgeon, it was an eye opener. I would be much obliged if the authors could answer a few questions I have. 1. How much of the capsule should be released, considering that we have to do the interportal capsular release and also the femoral neck capsular release since the authors stressed the importance of proper management of capsular release? Although we suture the capsule back before the skin closure, there is no proper information regarding the amount of capsular release.2 2. Since clinicoradiologically, the lesion was a cam lesion, can the excessive amount of femoral neck osteoplasty or resection be a cause of the patient’s anterior dislocation?3,4 3. Considering a female patient, what was her preoperative Beighton score? What are the chances that excessive ligament laxity might have been missed that would have been aggravated by the capsular release and femoral neck resection? I believe laxity can be one of the causes, considering the authors did not observe a capsular tear in the follow-up MRI. We close the capsule regularly in all our cases and believe it should be done without fail. Sarthak Patnaik, M.S.Ortho, F.S.S.I.S.A., F.A.S.M. Santander, Spain
Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.11.002
References 1. Austin DC, Horneff JG, Kelly JD. Anterior dislocation 5 months after hip arthroscopy. Arthroscopy 2014;30:1380-1382. 2. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br 2007;89:971-976. 3. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88: 925-935. 4. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404.
Author’s Reply To the Editor: I appreciate the inquiries by Dr. Patnaik and will attempt to answer them in sequence. 1. Regarding the volume of capsular release: In my opinion, the amount of capsular release should be just enough (but not more) to gain access to the femoral neck. The use of distraction portals and sutures can mitigate the need for complete iliofemoral ligament release. 2. Regarding cam resection as a source of instability: Theoretically cam resection does increase capsular laxity because it reduces the volume of intraarticular bone. Although excessive anterior neck resection can potentiate posterior subluxation in high hip flexion, I am not aware of any studies directly correlating bony cam resection alone with anterior instability. In our patient, I suspect the principle cause was anterior capsular laxity. 3. Regarding the issue of missed preoperative anterior instability: This question underscores the importance of more frequently recognized subtle anterior instability lesions of the hip, especially in female patients with ligamentous laxity. However, our patient did not display the characteristic straight anterior chondral wear pattern or direct anterior labral changes one would expect with anterior instability. Our patient showed the characteristic “wave sign” seen in cam impingement. I am grateful for Dr Patnaik’s questions and comments. Hip arthroscopists must be increasingly mindful of the role of instability, whether unrecognized or, as in this case, iatrogenic. More recent data suggest that better overall outcomes may be achieved with routine capsular closure.1
