Abstract
Background:
As the number of hip arthroscopies continues to rise, revision procedures have become increasingly common, with reported rates as high as 13.2%. Persistent functional limitation after primary hip arthroscopy is most often related to unresolved bony impingement, capsular insufficiency, or recurrent labral pathology.
Indications:
Revision hip arthroscopy is indicated when symptoms persist after primary surgery and an intra-articular source of the symptoms—such as inadequate or excessive bony resection, capsular mismanagement, or iatrogenic cartilage or labral injury—has been identified. Surgeons should also consider the potential need for the different open hip surgeries at this time and rule them out before proceeding with revision hip arthroscopy surgery.
Technique Description:
Revision hip arthroscopy starts with reviewing the previous operative note, obtaining standing anterior-posterior pelvis, 45° Dunn, and false profile radiographs, and, in our practice, performing a 3-dimensional (3D) computed tomography (CT) scan to assess for remaining bony impingement, as well as femoral version and tibial torsion. Magnetic resonance imaging arthrogram helps differentiate postoperative changes from new pathology. Intraoperatively, new portals are created as needed. Diagnostic arthroscopy assesses synovitis, adhesions, labral quality, capsular integrity, and any iatrogenic cartilage injury. Residual cam, pincer, or subspine impingement is addressed with the aid of 3D CT planning and intraoperative fluoroscopy to prevent over- and under-resection of bony pathology. Labral pathology is managed with a re-repair or tibialis anterior allograft reconstruction using the pull-through technique. Capsular insufficiency is addressed through imbrication in a figure-of-8 suture configuration or augmentation with suture anchors when the capsule cannot support additional sutures. Postoperative rehabilitation is similar to that of primary hip arthroscopy protocols with protected weightbearing and early motion precautions.
Results:
Revision hip arthroscopy is a safe and reliable procedure that improves pain and function in patients, although postoperative gains may be less than after primary arthroscopy. Complication rates are similar to primary arthroscopy, but the risk of conversion to total hip arthroplasty remains higher in the revision population.
Discussion/Conclusion:
When revision hip arthroscopy is appropriately indicated and performed, particularly with attention to residual bony impingement, labral pathology, and capsular integrity, it is a reliable option for patients with failed primary surgeries.
Patient Consent Disclosure Statement:
The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.
This is a visual representation of the abstract.
Video Transcript
We present our approach to revision hip arthroscopy: tips and tricks.
Background
With the growing use of hip arthroscopy across the United States and the world, we have seen an increase in revision hip arthroscopies. 2 In some literature, the revision hip arthroscopy rate has been reported as high as 13.2% of all arthroscopic procedures. 4 Most commonly, we see revision hip arthroscopy being performed for inadequate resection of the cam or other bony impingement. 3 While revision hip arthroscopy is not an ideal outcome of primary hip arthroscopy, fortunately, it continues to demonstrate reliable improvement in patient-reported outcomes.1,3,5-7
Indications
When approaching a failed hip arthroscopy, the indications for revision can be broken into 3 main categories. First, was it a failure of surgical indications? Second, was it a failure of surgical technique? Or third, was it a failure of the patient's postoperative course after the first hip arthroscopy?
A failure of indications would include indicating a hip arthroscopy when an alternative open hip preservation or replacement surgery should have been offered instead. Failure of technical execution of the surgery could include over- or under-resection of the bone, capsule mismanagement, or iatrogenic cartilage or labral damage. A failure of the patient's postoperative recovery could include failure to heal the labrum or capsule repair, failure to follow postoperative restrictions, which could compromise soft-tissue healing, or failure to appropriately rehabilitate the hip joint and surrounding musculature.
Technique Description
When evaluating a patient for a revision hip arthroscopy, the operative note from the previous procedure should be reviewed. New radiographs—including a standing anterior-posterior pelvis and 45° Dunn lateral and false profile view—should be obtained. In our practice, a preoperative 3-dimensional computed tomography (3D CT) scan is obtained for 3D imaging of the hip as well as measurements of the femoral version and tibial torsion. A magnetic resonance imaging (MRI) arthrogram is obtained to distinguish postoperative changes from new pathology, whereas a primary native hip evaluation includes an MRI without contrast. Diagnostic injections—including anesthetic-only or cortisone injection—can be used to confirm the intra-articular cause of the pain. Then, the physical examination can include many provocative maneuvers to assess intra- and extra-articular pathology, which can be used in combination to reach a diagnosis. 9
When evaluating a patient for revision hip arthroscopy, one should always keep in mind the alternative surgeries that are available—including a femoral derotational osteotomy, a periacetabular osteotomy, a surgical hip dislocation, or a total hip arthroplasty.
These should be offered to the patient in addition to consideration of revision arthroscopy, if they are indicated.
Once a revision hip arthroscopy is indicated, the patient is taken to the operating room and placed supine on a traction table. When pulling traction, the surgeon can assess capsular integrity by noting how easy it is to distract the hip. In the setting of a very easy hip distraction, this could indicate a capsular deficiency.
Marking out the previous hip arthroscopy portals can be helpful. However, new portals are created where most appropriate, guided by fluoroscopy, regardless of the location of the previous hip arthroscopy portals.
During the initial diagnostic arthroscopy, we evaluate for synovitis, adhesions, and chondral injury, and look for suture remnants from a previous labral repair or capsular closure. We specifically assess capsular integrity and note the ease of instrument entry. An easily accessible joint is a potential sign of capsular deficiency. We also want to take note of any iatrogenic injury to the acetabular or femoral head cartilage. You can see here that the femoral head cartilage injury likely occurred with the mid-anterior portal placement at the time of primary hip arthroscopy. The quality of labral tissue is assessed, which is when labral tears can be evaluated, and the determination of whether to perform a labral repair or a labral reconstruction can be made.
When entering the hip capsule, previous capsule closure sutures can be identified, and the thickness of the capsule can be assessed. Capsule deficiency, as shown here, can result in a large capsular defect. In some instances, a small band of scar tissue will falsely represent a closed hip capsule on preoperative MRI arthrogram.
The psoas tendon may also be visible through an anterior medial capsular defect, as shown in this video. There is a very thin layer of scar tissue between the joint and the psoas tendon, which appeared as an intact capsule on the MRI arthrogram imaging, but was not truly an intact capsule.
Addressing residual impinging bone, using the preoperative 3D CT scan helps identify areas of bone that may not be as clear, including subspine impingement, as shown here. The CT can also identify areas of residual cam impingement.
If subspine decompression is performed, care must be taken to maintain the origin of the direct head of the rectus femoris at the anterior inferior iliac spine .
If a rim or pincer resection is performed, care must be taken not to over-resect the acetabular rim, as this could lead to hip dysplasia or instability.
When performing a revision femoroplasty, care must be taken to protect the lateral retinacular vessels, which are the blood supply to the femoral head. Cautious resection should be performed to avoid over-resection of the femoral head-neck junction. Fluoroscopy can be used to confirm adequate resection, and once resection is complete, a dynamic assessment should be performed to ensure there is no further impingement.
If the labrum tissue is of adequate quality, a labral re-repair is indicated. However, take care to evaluate any eversion of the labrum and consider performing a labral advancement technique by placing anchors on the face of the acetabulum to prevent eversion of the labrum. After labor repair, careful assessment of the chondral labral junction will allow you to debride any loose chondral flaps in this area. If the quality of the labral tissue is not adequate, a labral reconstruction can be performed. Our preference is to use a tibialis anterior allograft and the pull-through technique. Once the labral graft is fixed, the residual labrum can be truncated with a radiofrequency ablation device. This should provide a nice suction seal to the hip joint.
For capsular closure, releasing overlying adhesions and soft tissue can help mobilize the intact capsule tissue. If there are areas of previous capsular dehiscence, this tissue can be gently debrided with a shaver, taking care not to overdebride the capsule. A robust capsular imbrication can be performed utilizing interrupted, nonabsorbable sutures with a figure-of-8 suture configuration for a complete capsular closure. Once the capsule closure is complete, it is important to ensure there are no incarcerated overlying tissues with the capsule closure. If the proximal limb of the capsule is not adequate to support sutures, additional suture anchors can be placed in the acetabular rim. These suture limbs can then be pulled through the distal capsule to bring the capsule back to the acetabular rim. When closing the interportal capsulotomy or utilizing sutures in the acetabular rim, our preference is to pass sutures with the hip in flexion but tie the sutures down with the hip in extension to avoid overtensioning the capsule closure.
Results
As with any primary hip arthroscopy, potential complications from a revision hip arthroscopy include residual impingement or over-resection of the bone, iatrogenic cartilage, injury to the femoral head or acetabulum, and heterotopic ossification after surgery, which can be prevented by administering indomethacin and other nonsteroidal anti-inflammatory drugs. Additional concerns in the revision setting include iatrogenic instability, especially if capsule tissue integrity is not as good as it was in the native setting, or if excessive bone resection leads to undercoverage of the hip socket. 10
Discussion/Conclusion
Postoperative rehabilitation for revision hip arthroscopy is similar to that for primary hip arthroscopy. The patient will be 20% weightbearing for 2 to 3 weeks after a labral repair or for 6 weeks after a labral reconstruction. We have specific motion restrictions for the first 6 weeks—including no external rotation beyond 30° and no hip hyperextension. Heterotopic ossification prophylaxis includes 4 days of indomethacin 75 mg daily, followed by Naprosyn for the first 30 days. We do not use deep vein thrombosis (DVT) chemoprophylaxis in otherwise healthy, ambulatory individuals, but we will provide it for patients at high risk of DVT. While some literature demonstrates that patients do not have as great an improvement after revision hip arthroscopy as with primary hip arthroscopy, there is significant literature supporting that revision hip arthroscopy can be successful in improving patient outcomes and function. There appears to be no differences in complication rates between revision and primary hip arthroscopy, and the risk of conversion to total hip replacement does, unfortunately, remain higher in the revision group compared to the primary hip arthroscopy group.1,3,4,7,8
Footnotes
One or more of the authors has declared the following potential conflict of interest or source of funding: A.M.S. is a paid consultant for Stryker. AOSSM checks author disclosures against the Open Payments Database (OPD). AOSSM has not conducted an independent investigation on the OPD and disclaims any liability or responsibility relating thereto.
