We read with great interest the study by Poutre et al. which investigates long-term outcomes of hip arthroscopy using the puncture capsulotomy technique.1 The authors report favorable 5-year results, including high rates of MCID achievement, low complication incidence, and an absence of revision surgeries. While this study is timely and clinically valuable, several interpretive and methodological issues warrant attention to contextualize its findings more critically. A major limitation stems from the absence of a comparative control group. Although the authors allude to favorable comparisons with other techniques such as interportal and T-capsulotomy, the lack of direct intrastudy comparison precludes definitive attribution of observed outcomes specifically to puncture capsulotomy. Reliance on historical benchmarks introduces confounding from evolving perioperative protocols, surgeon experience, and shifting patient selection over time.2 Additionally, the use of dislocation as a proxy for macroinstability and the absence of direct biomechanical assessment for microinstability limit the granularity of the stability claims. While the reported absence of clinical instability is encouraging, stability-related parameters such as joint translation or functional stress imaging were not measured. Furthermore, the lack of postoperative radiographs restricts insight into capsular healing or ossification extent, particularly as radiographic heterotopic ossification (HO) was the most common complication. Given the theoretical benefit of puncture capsulotomy in preserving capsuloligamentous structures,3 radiologic validation of capsular integrity would significantly strengthen the study's premise. The decision to forgo formal postoperative physical therapy across the cohort is another critical concern. While the authors suggest that early unstructured mobilization may minimize tissue strain, this introduces heterogeneity in recovery trajectories that may bias PROMs. The absence of standardized rehabilitation oversight complicates interpretation of outcome durability and raises concerns about long-term joint loading patterns, especially in the presence of residual osseous deformity or incomplete labral healing. Statistically, although the PROM improvements are significant, the authors do not report effect sizes, which are essential to judge clinical impact beyond statistical thresholds. Moreover, nearly 20% of enrolled patients lacked 5-year data, but no sensitivity analysis was performed to assess attrition bias, particularly if patients undergoing THA or with suboptimal recovery were underrepresented in follow-up responses. Finally, while low revision and THA conversion rates are encouraging, the study's reliance on chart review for complication reporting may underdetect events occurring outside the primary institution. Prospective registries or multicenter validation would better account for such events. In conclusion, while puncture capsulotomy appears promising, future studies should include matched control groups, objective capsular assessments, standardized rehabilitation, and robust radiographic follow-up to clarify its comparative advantages in hip arthroscopy. Generative AI tools, including Paperpal and ChatGPT-4o, were utilized solely for language, grammar, and stylistic refinement. These tools had no role in the conceptualization, data analysis, interpretation of results, or substantive content development of this manuscript. All intellectual contributions, data analysis, and scientific interpretations remain the sole work of the authors. The final content was critically reviewed and edited to ensure accuracy and originality. The authors take full responsibility for the accuracy, originality, and integrity of the work presented. All authors (R.S., A.M.) declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this article.
Sah et al. (Wed,) studied this question.