Although it seems logical that basic principles of hip preservation surgery such as understanding the pathomorphological mechanisms underlying disease states such as acetabular dysplasia and femoroacetabular impingement (FAI) should be part of the adult orthopaedic training curriculum, in reality, there is great variability in teaching these concepts in international training programs. Pediatric-based disease processes are widely taught as part of pediatric orthopaedic curricula, but diagnosis and management of young adult hip deformities frequently are not formally covered in sports medicine or adult reconstruction curricula. Also, different philosophies internationally such as a pathology-based approach in western Europe (hip or knee surgeon-specific) and treatment-based approach (joint arthroplasty versus arthroscopy) in the United States create difficulties in standardizing educational programs. The exposure in residency to these pathologies is limited except in isolated programs in which surgical preservation of the hip is performed and many residents finish their program without ever seeing or participating in joint-preserving procedures. For the most part, residency allows the resident a glimpse of the pathology and may heighten the graduating orthopaedic surgeon to its presence but does not prepare the resident to accurately diagnose or surgically treat these cases.
Contemporary fellowship training in hip preservation surgery is variable worldwide. Currently adult reconstructive fellowships may or may not include one or two rotations dedicated to joint preservation, whereas sports medicine fellowships may or may not include one or two rotations in hip arthroscopy. In the United States, we are aware of only two hip preservation fellowships offered for a 1-year duration. Internationally, hip preservation-specific fellowship training is also limited to perhaps two programs with variable exposure to currently recognized surgical techniques for FAI and hip dysplasia.
Therefore, multiple models for fellowship training exist including fellowships primarily emphasizing open surgical techniques and others emphasizing arthroscopic methods to treat primarily FAI. There is little agreement on what a comprehensive curriculum of educational material at the fellow level would look like. Furthermore, there is little agreement on the optimum length of training necessary to master techniques such as periacetabular osteotomy and basic hip arthroscopic techniques. The time dedicated within these fellowships to train the fellow in the diagnosis and surgical decision-making for either open or arthroscopic is limited and may not be sufficient to allow the fellow to return to unrestricted practice in joint preservation.
Current successful hip preservation surgeons have used a variety of methods to achieve refinement of the surgical technique and expansion of the knowledge base during early years of practice including self-driven surgeon visitation, cadaver work, and collaboration with more experienced surgeons. There is, however, a lack of formal mechanisms for mentorship, surgeon visitation, and formal training/cadaver courses available for those early practitioners who wish to incorporate such surgical techniques into their practice. However, recently the AAOS CME committee has formalized plans for the first AAOS surgical skills course focusing on hip preservation (July 2012, Rosemont, IL, USA).
A final piece of the training puzzle relates to lack of a formal society encompassing the area of hip preservation surgery. Whereas other subspecialties have successfully used specialty organizations or societies to create forums for education and surgical training, current practice related to the hip has been sporadic. The International Society for Hip Arthroscopy was created in 2007 and has successfully held large meetings focused primarily on arthroscopic surgical hip techniques. Courses emphasizing open surgical techniques have been limited largely to Berne, Switzerland, and occasionally in the United States under the Berne influence.
Directly related to the challenges in training for hip preservation is the relative paucity of data supporting the durability, functional restoration, and possibly prevention or delay of hip osteoarthritis provided by many of the operative interventions currently used for nonarthroplasty surgery of the hip. Long-term, ideally prospective, studies are needed to support current thought processes and further substantiate the effectiveness and value of current hip preservation techniques. Supportive evidence would strengthen the argument for inclusion of these concepts into training curricula. One current multicenter research body (ANCHOR [Academic Network of Conservational Hip Outcomes Research]) has successfully begun to provide data related to outcome and complication rates for hip preservation surgery.