Arthroscopic Management of Other Hip Disorders

Introduction

Complications of the posterior and posterolateral aspects of the hip have been extremely uncommon. A comprehensive understanding of the anatomy, biomechanics, clinical evaluation, and diagnostic strategies allows the physician to interpret the vast array of pathologies routinely encountered in the lateral and posterior hip. The comprehensive physical examination will help sort out the levels of pathology of the hip, including pathology involving the osseous, capsulolabral, musculotendinous, neurovascular, and kinematic chain ( Fig. 43.1 ). The kinematic chain in this region involves the pelvis and lumbar spine. The function of the hip as the longest lever and shortest lever arm contributes significantly to the strain parameters that are loaded downstream through the ligamentous structures, pelvis, and lower lumbar spine, and into the lower extremity. The critical factor involved with this load transfer is the planar torsional parameters in all three planes.

Hip arthroscopy has evolved since the original paper by Watanabe, and has further developed through time. Reports by Larson et al. ^, described the most common complications encountered with hip arthroscopy to be postoperative lateral femoral cutaneous nerve disturbance, iatrogenic chondral injuries and labral punctures, and superficial portal infections. The lateral-based technologies and our understanding of lateral-based pathology were further developed by Nawabi et al. through the peritrochanteric space endoscopy with minimal complications. Surgical strategies for the posterior hip have advanced circumferentially around the hip from the lateral to the posterior spaces. Posterior hip treatment techniques involving hamstring repair, lesser trochanterplasty, and sciatic nerve decompression from scar vascular bands or aberrant tendinous structures have been reported, with low complication rates. ^, ^, ^, This chapter will address the potential complications encountered during treatment of the lateral and posterior hip. The lateral and posterior regions will be further analyzed through each aspect of the patient encounter, including the preoperative, intraoperative, and postoperative time periods.

The goal for any surgery is to have an accurate diagnosis that accounts for all five levels of the hip. Insufficient understanding of hip anatomy and biomechanics have led to improper surgical selection in many patients. Proper education will guide outlining an appropriate plan for each of the five levels. Diagnostic strategies surrounding each of these five levels is critical for improving diagnostic acumen and patient safety. An incorrect diagnosis will likely lead to unfortunate complication, regardless of surgical expertise. A comprehensive evaluation encompassing a thorough history and physical examination will help most importantly to identify the correct pathophysiology and supply a treatment algorithm.

Lateral hip pathology encompasses peritrochanteric pain syndrome and torn gluteus minimus/medius muscles. Patients presenting with these specific pathologies usually complain of pain over the lateral aspect at the hip, which is increased by rising from a chair or climbing stairs. Pain is located over the anterior, lateral, or posterior facet. The anterior facet is more associated with tears involving the gluteus minimus, whereas the lateral facet is associated with the gluteus medius, and the posterior facet with increased tension or thickness within the iliotibial (IT) band. These pathologies can be identified through strength testing with abduction and adduction maneuvers, which evaluate overall tension and function. They frequently coexist with intraarticular complaints and should be sorted out. The most likely complication of lateral-based pathology is failure to recognize the lateral pathology contribution to the overall pathological symptoms. Table 43.1 provides a summary of the key preoperative, intraoperative, and postoperative complications associated with lateral hip- and posterior hip-based complaints. All phases of the treatment require understanding of the shared responsibility between the patient and caregivers to optimize outcome.

Table 43.1

Preoperative, Intraoperative, and Postoperative Complications Encountered for Pain Associated With the Lateral Hip and Posterior Hip

	Preoperative Complications	Intraoperative Complications	Postoperative Complications
Lateral-based pain	• Failure to properly diagnose pathology • Misdiagnosed imaging • Failure to recognize concomitant pathology	• Prolonged traction • Bleeding and hematoma formation • Fluid extravasation • Failure to identify undersurface tears • Poor operative patient positioning • Improper radiofrequency exposure or improper identification of neural tissue • Failure to release neurovascular bands that inhibit normal nerve mobility	• Poor strengthening compliance • Failure to adhere to crutch protocol
Posterior-based pain	• Failure to properly communicate expectations with patient • Failure to screen entire kinematic chain • Anxiety and depression • Abnormal hip biomechanics contributing to secondary strain		• Poor rehabilitation compliance and long-term follow-up • Excessive postoperative nerve strain • Failure to comply with knee brace protocol

Preoperative Complications

Lateral-Based Pain

The first potential complication that may arise with lateral-based complaints is failure to properly diagnose the lateral-based pathophysiology with the concurring other levels of pathological diagnosis. Once again, this requires a through comprehensive history and physical examination. One of the key factors in lateral-based evaluation is the radiographic interpretation. Undersurface tears of the hip abductors can be frequently misdiagnosed and missed. These tears can be associated with tendinopathy, and concomitantly with contracted IT bands. Multiplanar assessment can help to distinguish between these similarly presenting images and can be correlated with the physical examination. The quality of muscle on T2 magnetic resonance imaging (MRI) will help identify fatty muscle atrophy, which contributes to nonrepairable tendinous structure, requiring graft or gluteus maximus transfer.

Additional complications may arise in the case of misdiagnosis or by improperly identifying concomitant pathology. All hip examinations require spine examination, and all spine examinations require hip evaluation. The physician must be mindful of coexisting peritrochanteric pain syndrome created by a thickened IT band over a subtendinous tear of the gluteus minimus or gluteus medius. IT band contribution can be evaluated through fluoroscopic or ultrasound-guided injections to increase diagnostic accuracy of the inter/extraarticular concomitant pathologies.

Posterior-Based Pain

Preoperative posterior-based complications can be avoided with a complete understanding of the anatomy, biomechanics, clinical examination, and diagnostic strategies, and by correlating these factors with treatment options which involve both endoscopic and open techniques. The choice of approach should be directed by the experience of the surgeon. Adequate communication with the patient and screening for the coexisting pathologies of the hip and the entire kinematic chain are very important factors in the posterior hip. Anxiety and depression are both negatively correlated with surgical outcomes. Screening is especially important in the posterior hip, which involves neural structures. Delay in diagnosis is also associated with poor outcomes, which may be misinterpreted as a complication because of the lack of inherent healing within the nerve. The anatomic understanding of the hip should highlight the interrelationship between the pathology occurring in hip flexion contributing to posterior hip pain, as well as in hip extension–based pathologies. The biomechanics surrounding the hip and the strain transfers can precipitate problems that can be related both to the anterior side producing posterior pain, as well as posterior hip pain producing proximal secondary strain phenomena. These issues can be sorted out through good clinical examination, as previously outlined and described, and by diagnostic techniques. ^, Understanding the complex hip anatomy, biomechanics, and clinical presentation will allow for a comprehensive assessment to be completed for each of the five hip levels and avoid preoperative complications and confusions. Establishing proper treatment expectations and understanding patient-specific requirements are critical for patients presenting with lateral or posterior hip pain.

Intraoperative Complications

The most common intraoperative complications are associated with patient preparation. Biological and physiological effects can occur under traction, and the duration of traction should be minimized. Small bleeders frequently occur in the posterior aspect of the hip, as well as the posterior edge of the peritrochanteric space, requiring intermittent increases in pump pressure throughout the duration of the procedure. The elevated pump pressure can contribute to increased fluid extravasation when used over prolonged periods, thus it is recommended that only short intervals of increased pump pressure be used, that the core body temperature is monitored, and that intraabdominal tension is monitored on a regular basis through palpation of the abdomen.

Intraoperative potential complications involve the lack of familiarity with gluteus minimus and medius tear types, especially the undersurface tear. Domb et al. have outlined the importance of identifying the subtendinous tear and the approaches for assessing this pathology. Failure to recognize and address these etiologies leads to poor results and outcomes because the contributing pathology is not being addressed. The surgical technique involves single-row versus double-row repair, which contributes to success and stability of the repair. Gluteus minimus tears also have a specific orientation for portal placement to address anchor alignment angle, providing increased repair quality.

The endoscopic hamstring repair is outlined by Guanche et al. ^, Potential complications and risks as described by Guanche et al. include iatrogenic nerve structure damage because of the proximity of critical nervous tissue, infection, and fluid extravasation into the pelvis. We have found the pathology to be adequately addressed in the lateral position, or in the supine position with maximum contralateral tilt. This position seems to decrease the venous pressure, allowing less pump pressure to be used. This patient orientation allows for continuous monitoring of the abdominal tension.

The use of radiofrequency (RF) equipment in the posterior space has been reported, with safe use reports on the utilization of monopolar techniques ( Table 43.2 ). The temperature parameters encountered as a result of RF exposure in the posterior hip are acceptable; however, one should try to avoid direct RF exposure to the nerve to avoid the potential for any neural injury. The amount and frequency of selective monopolar probes are very safe at close proximity. RF exposure can be avoided altogether by tying off blood vessels in close approximation to the sciatic nerve itself. Frequently, fibrovascular bands need to be dissected free from the hamstring semimembranosis, semitendinosis, or biceps femoris when performing hamstring repair. Careful coagulation or ligature is performed, watching epineural blood flow, understanding the segmental nature of the vascularity involved.

Table 43.2

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