What did the study look at?
Hip arthroscopy for femoroacetabular impingement is becoming more common; one study cited by the authors found an 85% increase in a US insurance database between 2011 and 2018. As the number of operations grows, some fail.
Reasons for persistent pain after hip arthroscopy include residual impingement, hip dysplasia, progression of osteoarthritis, injury to the labrum (the cartilage ring around the hip socket) and inadequate closure of the joint capsule. How to treat graft tears in hips with a previous labral reconstruction is not yet well established in the literature. The article aims to describe an approach to revision arthroscopy in this situation.
How was it done?
This is a surgical technique article with a video. The patient described had previously undergone acetabuloplasty, femoroplasty, labral reconstruction with hamstring allograft and periacetabular osteotomy of the right hip, and still had impingement symptoms despite no visible lesion on x-ray.
- Before surgery: a thorough history and examination, a diagnostic lidocaine injection if needed to confirm the pain comes from inside the joint, and imaging. The authors stress that residual bony lesions may not show on x-rays.
- Central compartment: adhesions from previous surgery are carefully released; the capsule is opened as little as possible and traction sutures are placed for visibility. The torn graft is repaired with anchors from the 11 o'clock to the 1-3 o'clock position.
- Peripheral compartment: the residual cam lesion is reached through a T-shaped capsular incision (T-capsulotomy) and shaved (femoroplasty); adequate correction is checked with dedicated tools and dynamic examination.
- Closure: the capsule is closed; because this patient had a lax, redundant capsule, it was also tightened (plication).
Rehabilitation is divided into four phases, with safe return to sport targeted in phase 4 (weeks 16-32). Crutches can start to be discontinued after 3 weeks (6 weeks if microfracture was performed).
What did it find?
This is not an outcome study. The authors list pearls and pitfalls: missing the bony lesions that cause pain hampers planning; overlooking adhesions can lead to accidental labral injury; and large capsular incisions that are not closed properly can cause microinstability. They note a published series in which graft tears were found in 4 of 28 hips (14%) reoperated after labral reconstruction.
The authors' conclusion
The authors state that revision hip arthroscopy after labral reconstruction can be performed by following a systematic approach to diagnosing residual or recurrent problems. A previous periacetabular osteotomy need not complicate the procedure, provided the relevant angles are considered when preparing the socket rim. Repair of a previously reconstructed labrum is technically feasible.
Limitations
The authors state that further studies are needed to determine how well reconstructed labral tissue heals after it is fixed again.
Reference
Perry AK, Trasolini NA, Gürsoy S, Vadhera AS, Williams J, Nho SJ, Chahla J. (2022). Revision Hip Arthroscopy for Graft Retear and Residual Cam Lesion in a Previously Labral Reconstructed Hip. Arthroscopy Techniques, 11(2), e139-e145. Licence: CC BY-NC-ND 4.0.
DOI: 10.1016/j.eats.2021.10.003
Free full text: PubMed Central (PMC8821039)
This article summarises a published scientific paper for general information; it does not replace an examination or a personal medical assessment. Please consult your doctor about your symptoms.
