Evaluating the Failed Hip Arthroscopy

INTRODUCTION

The incidence of hip arthroscopy has been increasing over the last two decades.¹ Alongside, there is also an increase in the number of patients where hip arthroscopy fails to improve their pain and/or function. Certain populations have been identified that have less improvement after primary hip arthroscopy. These include patients over 40 years of age, females, those with acetabular dysplasia, and patients with relative femoral retroversion.²,³,⁴ As with most procedures, revision hip arthroscopy has less improvement in patient-reported outcomes than has primary hip arthroscopy.⁵ Evaluating the failed hip arthroscopy requires a thoughtful evaluation of why the primary procedure failed. Sometimes, the patient should not have been treated with hip arthroscopy in the first place, as in the setting of acetabular dysplasia, where a pelvic osteotomy would have likely been a more appropriate primary surgery. Alternatively, hip arthroscopy may have been appropriate but underresection of the cam deformity led to a poor outcome, requiring revision for complete resection of the pathoanatomy. These patients require a thorough and thoughtful approach to an evaluation of why their hip arthroscopy failed to maximize the outcome of nonoperative measures or revision surgery.

Clinical Scenario

A 25-year-old male comes in with recurrent left hip pain for the last 12 months. He has had two prior left hip arthroscopies. He had some improvement of his pain for approximately 1 year after the first surgery, which included a femoroplasty and labral repair, but his deep aching groin pain returned after a year. He then had a second surgery for debridement of adhesions and revision femoroplasty. He got no relief from the second surgery. Both surgeries were performed through an interportal capsulotomy without repair, and his presenting anteroposterior (AP) and lateral radiographs are presented in Figure 16.1.

FIGURE 16.1. A, Anteroposterior pelvis radiograph of a male who has had two prior hip arthroscopies. He has borderline acetabular dysplasia (lateral center edge [LCEA] 20°) and unresected lateral cam lesion (alpha angle of 82°). B, Lateral radiograph shows overresection in the anterior aspect of the femoral head-neck junction.

APPROACH

A series of questions must be answered in evaluating the failure of a prior hip arthroscopy. This approach is similar to that which can be used for a failed surgery of any kind. These questions are:

What was the original diagnosis and was it correct?
Had the patient failed appropriate nonoperative therapy before undergoing surgery?
What procedure was performed, and was it appropriate for the diagnosis?
Was the procedure technically well done?
Was the rehabilitation done appropriately, or are they underrehabilitated?
Are there other patient factors that may be clouding the patient’s outcome?
Has the patient developed degenerative disease that precludes revision preservation surgery?
How do you best address the failure with nonoperative or surgical interventions?

A systematic way of answering these questions should be developed to understand the reason for failure of the index surgery. There are many techniques that can be used to help answer these questions. As with the evaluation of any patient, the first step is history and physical examination. This is then augmented by a comprehensive radiographic evaluation of the hip, including all aspects of femoral and acetabular anatomy. Advanced imaging techniques, including computed tomography (CT) scanning and magnetic resonance imaging (MRI), are useful adjuncts to the radiographic evaluation. This chapter will go into comprehensive evaluation of the failed hip arthroscopy along with potential treatment options with case-based examples to illustrate the principles of evaluation and management of this difficult problem.

CLINICAL EVALUATION

History

In the setting of a failed surgery, the history has two important aspects to it. The first of these is the traditional patient-reported history of their symptoms and prior treatments, including their postoperative course after their first surgery. The second involves gathering all patient records available in regard to the prior surgery. This includes prior clinic notes, imaging tests, operative reports, and arthroscopic pictures from the previous surgery, when available.

The patient-reported history is important to obtain in relation to the current patient symptoms as well as the symptoms prior to the original surgery. Although patients suffer from some degree of recall bias, asking a complete history of their symptoms prior to the first surgery can be enlightening. This allows the surgeon to get an idea of how they would have approached the patient’s original problem. Important questions to ask in both settings are similar to evaluating any patient with hip pain. This starts with the locations of the patient’s pain and whether it radiates or whether there are other associated pains in the lower back or more distally in the extremity. Most, but not all, patients with intra-articular pain report the anterior groin as the most common area of pain. An important exacerbating factor is sitting or standing for long periods. Patients with structural instability from acetabular dysplasia commonly report increased pain while standing or walking for long periods, whereas patients with impingement have more pain with activities in positions of deep hip flexion including sitting for long periods of time or taking long car rides. Clicking or catching can be from multiple etiologies, including unstable labral tears, iliopsoas (or internal hip) snapping, iliotibial band (or external) snapping, or capsular insufficiency. Arthrofibrosis or intra-articular adhesions, commonly capsule-labral, can lead to patient-reported painful stiffness of the hip joint or pain with motion. Deep pain in the posterior aspect of the hip and/or radiation of pain down the leg could be indicative of missed lumbar spine pathology or ischiofemoral impingement, which may have been the etiology of the patient’s pain at initial presentation. However, ischiofemoral impingement is uncommon in the young patient population commonly treated with arthroscopy for femoroacetabular impingement (FAI).

In collecting the interval history after their index surgery, it is important to understand the degree of improvement the patient had after surgery. Some patients report an interval of improved symptoms, only to have the pain return after seemingly successful return to sport. This is common in the patients with undercorrection of impingement that have a soft tissue repair that is injured by continued bony deformity. In patients with structural instability from underlying acetabular dysplasia or excessive femoral anteversion, there is commonly lack of any improvement from surgery because hip arthroscopy can further destabilize an already unstable hip. Patients with impingement treated with cam decompression in the setting of femoral retroversion report improvement in symptoms but to less of an extent than those with normal femoral version. The amount of physical therapy and the type of exercises performed can evaluate the appropriateness of the rehabilitation. Exercises should focus on core strengthening and stabilization and hip abductor strengthening focusing on closed kinetic chain exercises, along with a comprehensive and progressive lower extremity-conditioning program.

It is important to acquire all documentation possible from the patient’s prior evaluation and treatment. This can include talking to the prior surgeon about the patient’s preoperative evaluation and postoperative course. Preoperative imaging and clinical notes can be used to evaluate the indications for the prior surgery, and operative notes and arthroscopic images can, in some cases, be
used to evaluate the quality and completeness of the procedure. The operative report and pictures are important for the technical aspects of the case that may or may not have been performed. For example, was the labrum torn, and was it repaired or was it torn and debrided? Is there a lack of labral tissue remaining? Was the labrum torn, and was it just left in this condition? In addition, it is important to determine how the capsule was managed. If there was an unrepaired capsulotomy or capsulectomy, then the patient may be suffering from hip instability without dislocation, referred to by some as hip microinstability.

Physical Examination

Examination starts with inspection and identification of prior operative scars. Palpation can sometimes elicit pain at portal sites or dysesthesias in the lateral femoral cutaneous nerve distribution. Palpation of the greater trochanter can elicit trochanteric bursitis or tendinopathy. Gait should be evaluated in all patients. In patients with a Trendelenburg stance or gait, one should worry about abductor tears or significant underrehabilitation after surgery. True abductor tears are much more common in the older patient population and are not commonly associated with younger patients undergoing surgery for FAI.

Supine physical examination should comprehensively test range of motion in hip flexion and internal rotation and external rotation at 90° of flexion. In underresected impingement, there is commonly decreased internal rotation in flexion. In the setting of adhesions or arthrofibrosis, there is generally a lack of internal and external rotation in flexion. Provocative tests include the impingement examination in flexion-adduction-internal rotation, which can be positive in unresected cam or unaddressed labral tear. Hip flexion with internal and external rotation in abduction can be painful with an underresected lateral cam lesion. Posterior impingement and/or anterior apprehension can be elicited in hip extension and external rotation with the contralateral knee held to the chest. Posterior buttock pain is indicative of posterior impingement and anterior apprehension or anterior-based pain is indicative of anterior instabilities or loading of an injured anterior chondrolabral junction. An axial traction test or dial test can be performed to further evaluate anterior capsular integrity after a failed hip arthroscopy. A toggling of the hip joint on axial traction or lack of an end point on dial testing can be signs of lack of iliofemoral ligament integrity after prior arthroscopy. Range of motion of the hip in extension in the prone position can be a good measure of femoral version where lack of internal rotation should raise suspicion for relative or absolute femoral retroversion. It is also important to note the symmetry of the exam, as commonly the symptomatic side has more femoral retroversion or lack of internal rotation. Excessive femoral anteversion can be seen with excessive internal rotation in both the prone and the supine positions. In patients with excessive internal rotation in flexion (>40°) after a hip arthroscopy for cam impingement, you should question whether cam impingent was the correct diagnosis, to begin with.

Strength testing can be helpful to understand functional deficits. In patients with prior psoas release, seated hip flexion is commonly weaker compared to the nonoperative side. Side-lying abduction strength testing should be performed in hip flexion, neural and extension. Patients who are still unable to engage their gluteus maximus and co-contract the maximus and medius commonly have weakness with resisted hip abduction in the extended position. This may be a sign of underrehabilitation or poor rehabilitation after prior surgery.

Imaging

A comprehensive radiographic evaluation of the proximal femur and acetabulum is needed to fully evaluate the prior operative interventions.⁶ The standing anteroposterior pelvis radiograph evaluates the lateral acetabular coverage and the femoral morphology at the superior position. In addition, the anterior and posterior wall indices can give you an idea of the anterior and posterior coverage of the acetabulum. The false profile radiograph evaluates anterior acetabular coverage and the anterior position on the femoral head-neck junction. We combine these two views with the 45° Dunn view, which evaluates approximately the anterior-superior to superior-anterior position on the anterolateral femur, which is the most common site of the cam morphology. We find that the lateral or superior position on the femur is the most common area of the cam deformity that is underresected in the revision setting. Important measurements to perform on these images include the lateral center edge angle (LCEA), Tönnis angle, anterior center edge angle, and the alpha angle on the femoral side. Acetabular retroversion can also be evaluated with the crossover sign, the posterior wall sign, the ischial spine sign, and the anterior and posterior wall indices, as well as the ratio between these indices. A summary of important radiographs to obtain and measurements to perform are presented in Table 16.1.⁶

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