Complications of arthroscopic surgery of the hip

Hip Arthroscopy: Common Problems and Solutions

The use of hip arthroscopy continues to expand. Understanding potential pitfalls and complications associated with hip arthroscopy is paramount to optimizing clinical outcomes and minimizing unfavorable results. Potential pitfalls and complications are associated with preoperative factors such as patient selection, intraoperative factors such as iatrogenic damage, traction-related complications, inadequate correction of deformity, and nerve injury, or postoperative factors such as poor rehabilitation. This article outlines common factors that contribute to less-than-favorable outcomes.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy

PURPOSE

Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury.

METHODS

MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted.

RESULTS

Twenty-four studies (n = 3405) were included, with the majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7 years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1 months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68 min with complication rates of 10% and 6.6%, respectively.

CONCLUSIONS

Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction.

LEVEL OF EVIDENCE

Level IV, systematic review of level I-IV studies.

Consecutive Bilateral Hip Arthroscopy for Symptomatic Bilateral Femoroacetabular Impingement in an Elite Rugby player: A Case Report

We report a case of concurrent bilateral hip arthroscopy for symptomatic bilateral femoroacetabular impingement (FAI) performed under the single anesthesia on an elite rugby player. A 27-year-old rugby player who played for a top league had bilateral hip joint pain. Physical examination revealed bilateral tenderness in the anterior area of the hips, with positive impingement signs. Based on the findings of hip radiography and magnetic resonance imaging, the patient's symptoms were diagnosed as bilateral FAI with hip labral tears. Bilateral hip arthroscopy under the single anesthesia was performed due to refractory symptoms. He returned to regular rugby games without any symptoms in either hip. Bilateral hip arthroscopic surgery under the single anesthesia should be an effective treatment for typical and symptomatic FAI, even in elite athletes.

Complications following arthroscopic surgery of the hip: a systematic review of 36 761 cases

AIMS

The number of patients undergoing arthroscopic surgery of the hip has increased significantly during the past decade. It has now become an established technique for the treatment of many intra- and extra-articular conditions affecting the hip. However, it has a steep learning curve and is not without the risk of complications. The purpose of this systematic review was to determine the prevalence of complications during and following this procedure.

MATERIALS AND METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used in designing this study. Two reviewers systematically searched the literature for complications related to arthroscopy of the hip. The research question and eligibility criteria were established a priori. Pertinent data were abstracted and analysed.

RESULTS

We found 276 relevant studies with a total of 36 761 arthroscopies that met the inclusion criteria. The mean age of the patients was 36.7 years (1.7 to 70) and the mean body mass index was 25.7 kg/m² (20.2 to 29.2). Femoroacetabular impingement and labral tears were the most common indications for the procedure. The total number of complications was 1222 (3.3%). Nerve injury (0.9%), mainly involving the pudendal and lateral femoral cutaneous nerves, and iatrogenic chondral and labral injury (0.7%), were the two most common complications. There were 58 major complications (0.2%), the most common being intra-abdominal extravasation of fluid, which was found in 13 cases (0.04%). There were three deaths (0.008%).

CONCLUSION

Arthroscopic surgery of the hip is a procedure with a relatively low rate of complications, although some may be significant in this young cohort of patients. This study relied on the reported complications only and the results should be interpreted with caution. Cite this article: Bone Joint J 2017;99-B:1577-83.

Combined Fluoroscopic and Arthroscopic Detection and Removal of a Foreign Body Lost During Elective Shoulder Arthroscopy: A Case Report

Introduction:

We report a case of a lost metal platelet from a radiofrequency ablation probe (VAPR VUE Radiofrequency System, Cool Pulse 90, DePuy, Synthes, Switzerland) in the shoulder joint during elective arthroscopic cuff repair. To the best of our knowledge, this kind of an incident during elective arthroscopy has not been described in the literature so far. In addition, we present an algorithm on how to deal with such an incident.

Case Report:

A 69-year-old woman underwent an arthroscopic subacromial decompression and rotator cuff repair for a torn supraspinatus tendon. While performing the subacromial decompression and after swapping the portals from lateral to posterior, the metal platelet of the electrocautery device got detached from the instrument and lost in the operation field. Several attempts to visualize the lost platelet with the camera failed. Finally, intraoperative fluoroscopic imaging was used to detect the platelet. To confirm the definitive whereabouts of the platelet, two spinal needles were positioned perpendicular to another under x-ray control, both pointing at the missing platelet. After determining the exact location, the platelet could finally be visualized with the camera and removed. Due to this incident, the operation time was extended extensively, and the patient as well as the theatre team was exposed to an unnecessary amount of radiation.

Conclusion:

This report indicates that an extraordinary incident such as the detachment of a component of the arthroscopic equipment during surgery is possible and should be kept in mind by the surgeon. Therefore, we believe that it is essential to perform a test of integrity at least at the end of every operation. In addition, we are presenting an algorithm on how to deal with the situation of a lost foreign body during arthroscopy, which can be applied to any joint.

Intraoperative Radiation Exposure During Hip Arthroscopy

BACKGROUND

The frequency of hip arthroscopy for the treatment of acute and chronic chondrolabral pathology and femoroacetabular impingement (FAI) has increased exponentially over the past decade. While surgeon and patient radiation exposure has been well documented in other areas of the orthopaedic literature, little is known about the procedure-specific and cumulative doses affecting the hip arthroscopist.

PURPOSE

To determine the mean annual radiation exposure to the hip arthroscopist and the mean surgeon exposure per case.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

A total of 210 consecutive hip arthroscopies performed in 209 patients by a single surgeon at a single ambulatory surgical center in a cohort consisting of approximately 50% bony (cam and pincer) pathology were prospectively reviewed, documenting the specific procedures performed in each case and the readings from a radiation dosimeter worn by the surgeon during positioning and while performing the procedures. Radiation readings for deep dose-equivalent (DDE), lens dose-equivalent (LDE), and shallow dose-equivalent (SDE) were measured. These readings were compared with the annual radiation dose limit recommendations established by the International Commission on Radiological Protection (ICRP).

RESULTS

The total radiation doses for the operative surgeon during all 210 cases were 183 mrem (1.83 mSv) DDE, 183 mrem (1.83 mSv) LDE, and 176 mrem (1.76 mSv) SDE. The mean exposure per case was 0.871 mrem (0.00871 mSv) DDE, 0.871 mrem (0.00871 mSv) LDE, and 0.838 mrem (0.00838 mSv) SDE. The operative surgeon's mean annual exposure, performing 70 hip arthroscopies per year with 55% involving bony work, was 61.0 mrem (0.610 mSv) DDE, 61.0 mrem (0.610 mSv) LDE, and 58.7 mrem (0.587 mSv) SDE. These results are well below the ICRP annual limits of 50,000 mrem (500 mSv) DDE, 2000 mrem (20 mSv) LDE, and 50,000 mrem (500 mSv) SDE.

CONCLUSION

For an experienced hip arthroscopist utilizing fluoroscopy during setup and bony resection, the annual and per-patient exposure to radiation remains well below the recommended ICRP limits.

CLINICAL RELEVANCE

Considering the increasing annual frequency of hip arthroscopies being performed, information regarding procedure-specific and cumulative doses of radiation exposure affecting the hip arthroscopist may provide valuable safety information for the orthopaedic community.

Hip arthroscopy protocol: expert opinions on post-operative weight bearing and return to sports guidelines

The objectives of this study are to survey the weight-bearing limitation practices and delay for returning to running and impact sports of high volume hip arthroscopy orthopedic surgeons. The study was designed in the form of expert survey questionnaire. Evidence-based data are scares regarding hip arthroscopy post-operative weight-bearing protocols. An international cross-sectional anonymous Internet survey of 26 high-volume hip arthroscopy specialized surgeons was conducted to report their weight-bearing limitations and rehabilitation protocols after various arthroscopic hip procedures. The International Society of Hip Arthroscopy invited this study. The results were examined in the context of supporting literature to inform the studies suggestions. Four surgeons always allow immediate weight bearing and five never offer immediate weight bearing. Seventeen surgeons provide weight bearing depending on the procedures performed: 17 surgeons allowed immediate weight bearing after labral resection, 10 after labral repair and 8 after labral reconstruction. Sixteen surgeons allow immediate weight bearing after psoas tenotomy. Twenty-one respondents restrict weight bearing after microfracture procedures for 3–8 weeks post-operatively. Return to running and impact sports were shorter for labral procedures and bony procedures and longer for cartilaginous and capsular procedures. Marked variability exists in the post-operative weight-bearing practices of hip arthroscopy surgeons. This study suggests that most surgeons allow immediate weight bearing as tolerated after labral resection, acetabular osteoplasty, chondroplasty and psoas tenotomy. For cartilage defect procedures, 6 weeks or more non-weight bearing is suggested depending on the area of the defect and lateral central edge angle. Delayed return to sports activities is suggested after microfracture procedures. The level of evidence was Level V expert opinions.

Vascular Coloration for Anatomical Study of the Pelvis and Hip: Implications in Hip Preservation Surgery

Hip preservation surgical techniques have steadily increased in the recent past. Therefore, precise knowledge of the vascular system of the hip and pelvis is critical for avoidance of possibly devastating complications during surgery. A colored latex injection in the common iliac artery of cadavers allows for a complete staining of the hip and pelvis vascular system. This technique creates more resilient vessels, whereas coloration with dye causes the vessels to be highly visible in comparison with the surrounding tissue. The proposed colored latex-dye solution injection allows for complete identification of the circulatory system of the lower extremity with specific focus on the hip and pelvis. This technique is simple, reproducible, and easily usable by orthopaedic surgeons in the laboratory to better understand the vascularization of the lower limb. The purpose of this technical note is to describe our technique for the injection of latex-dye solution in the common iliac artery, followed by dissection to key vascular structures of the hip and pelvis.

Traction-related problems after hip arthroscopy

Traction-related problems are poorly described in the existing literature. The purpose of this prospective study was to describe traction-related problems and how patients perceive these problems. The study was a descriptive cohort study and data were collected from questionnaires and patient files. The questionnaire included questions on patients' perceptions of traction-related problems in the groin area, at the knee and ankle and how patients had coped with these problems. A total of 100 consecutive patients undergoing hip arthroscopy filled out the questionnaire. Primary findings of this study were that 74% of patients reported some sort of traction-related problems after hip arthroscopy. About 32% of the patients had problems in the groin area and 49% of the patients complained of symptoms in the knee joint. A total of 37% of the patients had experienced problems from the traction boot in the ankle area. The complications were found to be temporary and disappeared after 2-4 weeks. Five patients still had complaints after 3 months. All five patients had a pre-existing knee injury prior to undergoing hip arthroscopy. Traction-related problems after hip arthroscopy are a challenge and our study showed that 74% of the patients reported traction-related problems. This is significantly higher than previously reported. The present study found a high rate of complaints from the knee and ankle joints that have not previously been reported. The presented data suggest the need for more pre-surgery patient information about possible traction-related problems.

Patient-specific factors influencing the traction forces in hip arthroscopy

INTRODUCTION

The application of traction in hip arthroscopy is associated with peri-operative complications. Within a therapeutic case series, patient-related factors correlating with high-traction forces during hip arthroscopy and occurring complications should be identified.

MATERIALS AND METHODS

In 30 male and 38 female patients (mean age: 44.5 years), intra-operative traction forces were monitored continuously using a specialised measurement device. A multivariate analysis was employed to identify patient-related factors influencing the traction force. Peri-operative complications (follow-up: 12 weeks) were evaluated by performing a single-case analysis.

RESULTS

The mean initial force prior to penetration of the capsule ("initial force") was 477 N (men: 517 N; women: 444 N), decreasing after capsulotomy by an average of 17 %. The male gender (p < 0.001), Kellgren and Lawrence radiographic stage (p = 0.037), low minimum joint-space width (p = 0.029) and high body height/weight (p = 0.003/0.037) correlated significantly with higher distraction forces. The patient age and type of anaesthesia (general versus spinal) were not relevant. Complications were observed in ten patients on the first post-operative day. In two of these patients a partial sensory deficit of the lateral cutaneous femoral nerve persisted after 12 weeks. All patients with complications required initial traction forces of >400 N.

CONCLUSIONS

The study revealed several patient-specific risk factors correlating with high-traction forces during hip arthroscopy. With view to potential complications, these patient groups require special attention during surgical treatment as well as in future studies.

Arthroscopic hip preservation surgery practice patterns: an international survey

To design and conduct a survey analyzing pre-, intra- and post- hip arthroscopy practice patterns among hip arthroscopists worldwide. A 21-question, IRB-exempt, HIPAA-compliant, cross-sectional survey was conducted via email using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. Seventy-five respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing AP pelvis, false profile and Dunn 45 were the most common radiographs utilized. CT scans were utilized by 54% of surgeons at least some of the time. Only 56% of participants recommended an arthrogram with MRI. Nearly all surgeons either never (40%) or infrequently (58%) performed arthroscopy in Tönnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51% never; 44% infrequently). Only 25% of participants perform a routine 'T' capsulotomy and 41% close the capsule if the patient is at risk for post-operative instability. Post-operatively, 52% never use a brace, 39% never use a continuous passive motion, 11% never recommended heterotopic ossification prophylaxis and 30% never recommended formal thromboembolic disease prophylaxis. Among a large number of high-volume experienced hip arthroscopists worldwide, pre-, intra- and post- hip arthroscopy practice patterns have been established and reported. Within this cohort of respondents, several areas of patient evaluation and management remain discordant and controversial without universal agreement. Future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Hip arthroscopic capsulotomy techniques and capsular management strategies: a systematic review

PURPOSE

Hip arthroscopy is increasingly used to address hip joint pathology. Iatrogenic instability has been reported as a potential complication, leading to the evaluation of various capsular management strategies. The purpose of this review was to (1) report the techniques used for capsulotomy in hip arthroscopy, (2) understand techniques and indications for capsular closure, and (3) report outcomes based on capsular management strategy.

METHODS

MEDLINE, EMBASE, and PubMed were searched and screened in duplicate for relevant studies. Data regarding patient demographics, indications, surgical technique, rehabilitation strategies, and complication rates were obtained. Study quality was assessed in duplicate using the Methodological Index for Non-Randomized Studies (MINORS) Criteria.

RESULTS

Eighty-two studies of primarily level IV evidence (80 %) and of fair quality involving 4504 patients with a mean age of 35 years old (range 1.2-82 years) were included. Fifty percent of patients were male. Mean follow-up was 24.9 months (range 5 days to 13 years). Of 68 studies reporting capsulotomy technique (only 7 % of all otherwise eligible studies), 55 % performed an interportal capsulotomy while 24 % performed a T-capsulotomy. Of 36 studies reporting capsular management strategy post-arthroscopy, 22 % did not repair the capsulotomy, 6 % routinely performed partial repair, and 50 % performed complete repair. Of three studies (206 patients) directly comparing capsular management strategies, only one study found a statistically significant difference between complete and partial repair on the Hip Outcome Score-Sport Specific Subscale, though this difference was less than the minimal clinically important difference (83.6 versus 87.3). The total rate of reported post-operative dislocation, instability, or instability was 0.3 % (5 patients).

CONCLUSIONS

Technical details regarding capsulotomy and capsular management post-hip arthroscopy are not consistently reported in the literature. Capsulotomies are most often performed using an interportal technique, and more recent studies report routine closure. Overall, post-operative instability is rare and there is no consistent trend for capsular management strategy. Given current evidence, there is little basis on which to establish the relationship between surgical technique and post-operative instability or long-term consequences (e.g., kinematic changes). Thus, while capsular closure/plication may be suitable for specific populations (i.e., dysplasia or laxity), evidence-based indications for capsular repair remain unclear.

LEVEL OF EVIDENCE

Level IV, systematic review of level I-IV Studies.

Complications in Hip Arthroscopy

BACKGROUND

Recent developments in hip arthroscopic techniques and technology have made it possible in many cases to avoid open surgical dislocation for treating a variety of pathology in the hip. Although early reports suggest favourable results' using hip arthroscopy and it has been shown to be a relatively safe procedure, complications do exist and can sometimes lead to significant morbidity.

METHODS

This is a review article. The aim of this manuscript is to present the most frequent and/or serious complications that could occur at or following hip arthroscopy and some guidelines to avoid these complications.

CONCLUSION

Most complications of hip arthroscopy are minor or transient but serious complications can occur as well. A lot of complication e.g. acetabular labral puncture go unreported. Appropriate education and training, precise and meticulous surgical technique with correct instrumentation, the right indication in the right patient and adherence to advice from mentors and experienced colleagues are all essential factors for a successful outcome. Level of evidence: V.

Topographic anatomical study of the sciatic nerve relationship to the posterior portal in hip arthroscopy

OBJECTIVE

To evaluate the anatomic topographic relation between the sciatic nerve in relation to the piriform muscle and the posterior portal for the establishment of hip arthroscopy.

METHODS

We dissected 40 hips of 20 corpses of adult Brazilians, 17 male and three female, six black, six brown and eight white. We studied the anatomical relationship between the sciatic nerve and the piriform muscle with their variations and the distance between the lateral edge of the sciatic nerve and the posterior portal used in hip arthroscopy. We then classified the anatomical alterations found in the path of the sciatic nerve on the piriform muscle.

RESULTS

Seventeen corpses had bilateral relationship between the sciatic nerve and the piriform muscle, i.e., type A. We found the following anatomical variations: 12.5% of variant type B; and an average distance between the sciatic nerve and the portal for arthroscopy of 2.98cm. One body had type B anatomical variation on the left hip and type A on the right.

CONCLUSION

the making of the posterior arthroscopic portal to the hip joint must be done with careful marking of the trochanter massive; should there be difficult to find it, a small surgical access is recommended. The access point to the portal should not exceed two centimeters towards the posterior superior aspect of the greater trochanter, and must be made with the limb in internal rotation of 15 degrees.

Compression and Flip Test for Diagnosis of Unstable Acetabular Labral Tears Using a Peripheral Compartment Approach

Assessment of integrity of the acetabular labrum is generally done via the central compartment under distraction of the femoral head from the acetabulum. With the technique of raising the extra-articular and peripheral compartment first, there is a need for testing the stability and function of the labrum from the peripheral side in a nondistracted position of the joint. The authors report on the compression and flip test (i.e., the flip test) for the detection of unstable, intrasubstance tears of the labrum or unstable chondrolabral separations. The test can be performed by compressing the labrum with blunt instruments. We grade the labral conditions as follows: grade 0 for firm resistance and elasticity to palpation, grade 1+ as easily compressed by the probe, grade 2+ for eversion of the body of the labrum under compression), and grade 1 for ossified, hard resistance without any elasticity and compressibility. This test can be performed directly after accessing the peripheral compartment through a 2-portal technique without extensive capsular work.

Hip arthroscopy complications regarding surgery and early postoperative care: retrospective study and review of literature

PURPOSE

The purpose is to describe the rate of complications in a series of hip arthroscopies performed at our center, as well as perform a systematic review of the current literature in order to compare our outcomes.

METHODS

Two hundred and fifty-eight patients affected of femoroacetabular impingement and treated with hip arthroscopy have been studied. All minor and major complications were studied during the first postsurgery year. Furthermore, a systematic review was performed comparing major and minor complications with our series. Two attending orthopedic surgeons selected the different studies with the same inclusion and exclusion criteria, remaining with 48 studies that have been reviewed and included in the present study.

RESULTS

Mean age was 36.6 years old (SD 17.45), and the ratio men:women was 137:121. The mean complication rate observed was 14.34% (37/258) of global complications. Only three patients showed major complications: femoral neck fracture, septic arthritis and avascular necrosis of the femoral head. Any of these patients had permanent side effects.

CONCLUSIONS

Hip arthroscopy has a low rate of major complications, but a higher number of minor complications that could be avoided with certain preventive measures.

Surgical anatomy of the sciatic nerve: A meta-analysis

The sciatic nerve has varying anatomy with respect to the piriformis muscle. Understanding this variant anatomy is vital to avoiding iatrogenic nerve injuries. A comprehensive electronic database search was performed to identify articles reporting the prevalence of anatomical variations or morphometric data of the sciatic nerve. The data found was extracted and pooled into a meta-analysis. A total of 45 studies (n = 7068 lower limbs) were included in the meta-analysis on the sciatic nerve variations with respect to the piriformis muscle. The normal Type A variation, where the sciatic nerve exits the pelvis as a single entity below the piriformis muscle, was most common with a pooled prevalence of 85.2% (95%CI: 78.4-87.0). This was followed by Type B with a pooled prevalence of 9.8% (95%CI: 6.5-13.2), where the sciatic nerve bifurcated in the pelvis with the exiting common peroneal nerve piercing, and the tibial nerve coursing below the piriformis muscle. In morphometric analysis, we found that the pooled mean width of the sciatic nerve at the lower margin of the piriformis muscle was 15.55 mm. The pooled mean distance of sciatic nerve bifurcation from the popliteal fossa was 65.43 mm. The sciatic nerve deviates from its normal course of pelvic exit in almost 15% of cases. As such we recommend that a thorough assessment of sciatic nerve variants needs to be considered when performing procedures in the pelvic and gluteal regions in order to reduce the risk of iatrogenic injury. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:1820-1827, 2016.

Iliotibial band syndrome following hip arthroscopy: An unreported complication

BACKGROUND

Hip arthroscopy is considered a safe procedure, considering the relatively low rate of complications. Despite several complications have been described following this surgical procedure, the present event has not yet been described. The purpose of the present study is to report an unpublished complication following hip arthroscopy, after reviewing 162 hip arthroscopies and finding iliotibial band syndrome (ITBS) in the knee during followup.

MATERIALS AND METHODS

A retrospective review of 162 hip arthroscopies performed between September 2007 and June 2011 was carried out, evaluating patients who presented ITBS during followup. Indication for hip arthroscopy was failure of conservative treatment in patients with symptomatic femoroacetabular impingement.

RESULTS

During a minimum followup of 2 years, nine patients (5.5%) developed ITBS. All patients were diagnosed with ITBS within the first 45 postoperative days. Conservative treatment was successful in 6 patients while 3 had to undergo surgery. The increased internal rotation, synovitis and increased adduction of the hip can be attributed as predisposing factors to the development of ITBS.

CONCLUSIONS

This is a newly described observation within followup of hip arthroscopy. These findings may help orthopedic surgeons when planning rehabilitation after hip arthroscopy, including stretching exercises to prevent this syndrome.

A review of important medical and surgical considerations for obese patients undergoing arthroscopic surgery

Obesity represents a unique challenge in orthopaedic surgery, the impact of which is seen through all phases of injury: in the development of disease, during the operative procedure, and throughout the rehabilitation period. Given the high prevalence of obesity in the United States and around the world, this patient population represents a substantial proportion of patients in need of orthopedic care. The effects of this disease constrain both medical and financial resources. For obese patients undergoing orthopedic procedures, adequate steps must be taken to minimize the risks that occur before, during, and after surgical intervention. This literature review discusses the impact of obesity on arthroscopic procedures, with a focus on procedures involving the shoulder, hip, and knee. The management of obese patients during the perioperative period should address the specific concerns relating to these patients. Obesity is a risk factor for numerous comorbidities, is associated with surgical complications, and is a predictor of poor functional outcomes following arthroscopy. Efforts to minimize the negative impact of obesity on arthroscopic procedures are crucial.

Anesthesia for hip arthroscopy: a narrative review

PURPOSE

Hip arthroscopy is a minimally invasive surgical procedure indicated for the treatment of specific hip disorders. In this narrative review, we aim to examine the key components in providing anesthesia for this procedure.

SOURCE

MEDLINE(®), PubMed, and EMBASE™ databases were searched for peer-reviewed articles discussing the anesthetic management of patients undergoing hip arthroscopy.

PRINCIPAL FINDINGS

The primary anesthetic regimen used for hip arthroscopy should balance patient factors, preferences of the surgeon, and the demands of the procedure itself. Both general and neuraxial anesthetic techniques are well suited for this mostly ambulatory surgical procedure. There is a lack of current literature specifically comparing the benefits and risks of the two techniques in this setting. Postoperative pain management consists mainly of intravenous and oral opioids; however, a variety of regional anesthesia techniques, such as lumbar plexus block and fascia iliaca block, can be performed pre- or postoperatively. Overall, hip arthroscopy is safe, although positioning-related difficulties, extravasation of irrigation fluid, hypothermia, infections, and thromboembolic events are potential perioperative complications that warrant specific monitoring and prompt treatment.

CONCLUSIONS

Until now, the anesthetic technique for hip arthroscopy has not been well studied. Thus, increasing emphasis should be directed towards examining relevant clinical outcomes that can better inform evidence-based decision-making in the anesthetic management of hip arthroscopy patients. In the meantime, awareness of potential complications and vigilant monitoring are paramount in providing safe anesthetic care for patients undergoing hip arthroscopy.

Arthroscopic Femoral Osteochondroplasty for Cam-Type Femoroacetabular Impingement: The Trough Technique

Arthroscopic osteochondroplasty has become the most common treatment for cam-type femoroacetabular impingement. However, gauging the appropriate depth and location of the femoral osteochondroplasty remains challenging, given the parallax observed from using a 70° arthroscope across multiple viewing perspectives. Consequently, reliable techniques must use a combination of arthroscopic and fluoroscopic checks and balances to assess the femoral head-neck junction to help guide bony resection. We have developed a technique for osteochondroplasty that has made the process more efficient and reliable in our hands. It involves creating a trough at the apex of the osteochondroplasty and then contouring the proximal and distal regions to re-create normal proximal femoral geometry. This article details our technique for femoral osteochondroplasty, which can be performed alone for isolated cam impingement or in concert with other intra- and extra-articular procedures to address associated hip pathology.

Trends in Arthroscopic Procedures Performed During Orthopaedic Residency: An Analysis of Accreditation Council for Graduate Medical Education Case Log Data

PURPOSE

To analyze orthopaedic resident case log data to report temporal trends in performing arthroscopic procedures and to assess variability in arthroscopic case volume among residents.

METHODS

Accreditation Council for Graduate Medical Education orthopaedic surgery resident case logs were reviewed from 2007 to 2013. The mean number of wrist, elbow, shoulder, knee, and ankle arthroscopic procedures performed by graduating residents was analyzed. The median number of arthroscopic procedures reported by the 70th and 30th percentiles of graduating residents (by arthroscopic case volume) was also recorded. Temporal trends were assessed using a linear regression model.

RESULTS

From 2007 to 2013, there were significant increases in the mean number of wrist (5.8 to 6.3; P = .038), elbow (2.5 to 3.2; P < .001), shoulder (93.5 to 133.8; P < .001), knee (170.6 to 185.1; P = .011), and ankle (5.8 to 7.4; P < .001) arthroscopies performed per resident. Residents in the 70th percentile of caseload performed significantly more wrist (7 v 2; P < .001), elbow (3.3 v 1; P < .001), shoulder (134.1 v 70.6; P < .001), knee (205 v 128.7; P < .001), and ankle (7.9 v 2.9; P < .001) arthroscopies than residents in the 30th percentile.

CONCLUSIONS

Our findings indicate that arthroscopic caseload is increasing among orthopaedic residents. However, resident experience performing arthroscopic procedures is substantially disparate. Although the educational implications of this disparity are not well understood, our findings may aid in efforts to optimize arthroscopic training during orthopaedic residency.

Vulvar necrosis after surgical treatment of femoral neck fracture: a case report and investigation of the mechanism of injury

We report the case of a young patient, presenting with total bilateral vulvar necrosis after reduction of a femoral neck fracture. This report describes the management of this complication, its mechanism of injury and the associated means of prevention. We present an investigation of the vulvar vasculature in order to understand the mechanism of injury.The study of the vulvar vasculature rejects the anatomical hypothesis of selective damage to the internal and external arteries. Instead, it suggests intraoperative impingement of the terminal blood vessels caused by compression against the perineal post prompting discussion on the use of moulded countertraction posts during orthopaedic surgery.

Open and Arthroscopic Surgical Treatment of Femoroacetabular Impingement

Femoroacetabular impingement (FAI) is a common cause of hip pain, and when indicated, can be successfully managed through open surgery or hip arthroscopy. The goal of this review is to describe the different approaches to the surgical treatment of FAI. We present the indications, surgical technique, rehabilitation, and complications associated with (1) open hip dislocation, (2) reverse periacetabular osteotomy, (3) the direct anterior “mini-open” approach, and (4) arthroscopic surgery for FAI.

Perineal Post Padding Technique to Improve Hip Distraction in Tall Patients

Hip distraction is necessary for safe arthroscopic entry into the hip joint. Achieving sufficient distraction is difficult in exceedingly tall patients (>190.5 cm) because of size limitations of currently available hip distraction systems. Inadequate distraction can delay the surgical procedure and potentially lead to complications. By repurposing a foam head-positioning block, we report a safe and inexpensive positioning technique for extending the traction distance for tall patients by 2 inches.

The Effect of Traction Force and Hip Abduction Angle on Pudendal Nerve Compression in Hip Arthroscopy: A Cadaveric Model

PURPOSE

To investigate the site of pudendal nerve compression and the relation between traction force and abduction angle regarding pressure levels at setup for hip arthroscopy.

METHODS

A total of 17 hips from 9 fresh-frozen cadavers (6 male and 3 female cadavers) were used. The pudendal nerves were dissected, and 3 FlexiForce force sensors (Tekscan, Boston, MA) were implanted on the pudendal nerve where the inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris/penis emerge. A custom-made traction table in a supine position was used with a padded perineal post of 9 cm. Recordings were made at 0, 10, 20, 30, and 40 kg of traction at varying hip abduction angles of 0°, 15°, 30°, and 45°.

RESULTS

The tuber ischiadicum (perineal nerve) and genital region (dorsal nerve of penis/clitoris) had statistically higher pressure values when compared with the pudendal canal (inferior rectal nerve) (P < .05). There was a significant increase in forces acting on the pudendal nerve with increasing application of 0 to 40 kg of traction in steps of 10 kg, with the exception of the pudendal canal sensor and reading of the perineal nerve sensor at 45° of hip abduction (P < .004 with Bonferroni correction for significant values). On the contrary, hip abduction angle had no statistically significant effect on pudendal nerve compression. (All specific P values with Bonferroni correction were greater than .003.)

CONCLUSIONS

To avoid nerve palsy completely, the etiopathogenesis of compressive neuropathy should be identified. The location for compression and relation between different traction positions and forces are clarified in this study. This information can be used for further research and prevention.

CLINICAL RELEVANCE

This study adds objective data on the etiopathogenesis of pudendal nerve compression, which potentially contributes to prevention of pudendal nerve palsy as a common complication of hip arthroscopy.

Comparison of Pre- and Postoperative Hemoglobin and Hematocrit Levels in Hip Arthroscopy

Purpose :

to assess the loss in hematocrit and hemoglobin, if any, 24 hours after hip arthroscopy.

Methods :

thirty-five patients were included. Laboratory tests including complete blood count and white blood cells were performed one week prior to surgery and 24 hours after. Surgical time, volume of saline perfusion and pump perfusion was also recorded.

Results :

mean preoperative hematocrit was 42.01% (4.63 SD), whereas mean postoperative hematocrit at 24 h decreased to 36.78% (SD 5.11) (p <0.021.). Mean preoperative hemoglobin was 14.23 g/dL (1.73 SD), and mean postoperative hemoglobin at 24 h decreased to 12.40 g/dL (SD 1.92) (p =0.03.). Platelets and white blood cells, as well as the remaining biochemical parameters showed no significant difference between preoperative and postoperative samples. Lost blood volume worked out with the logarithmic method for estimated blood loss was which 0.78 liters (SD 0.45). Lost blood volume taking into account, the red blood cell mass was also 0.78 liters (SD 0.45).

Conclusion :

a significant decrease in hemoglobin and hematocrit after hip arthroscopy was observed. Although patients did not show clinical signs of anemia or bleeding, blood loss should be considered when planning a hip arthroscopy, especially in patients at risk of anemia. According to our results, we recommend a postoperative control analysis at 24 h.

Level of Evidence :

level II, Diagnostic Study.

REHABILITATION AFTER HIP ARTHROSCOPY AND LABRAL REPAIR IN A HIGH SCHOOL FOOTBALL ATHLETE: A 3.6 YEAR FOLLOW-UP WITH INSIGHT INTO POTENTIAL RISK FACTORS

BACKGROUND

Hip arthroscopy is a common surgical technique for the correction of intraarticular pathology. While surgical success is often determined by anatomical correction, post-operative rehabilitation serves an essential role in restoring pre-morbid activity levels. A paucity of long-term post-operative rehabilitation outcomes exists in the literature lending uncertainty to the long-standing efficacy of interventions and associated risk for future injury.

CASE DESCRIPTION

This case report describes the progress of a male subject 3.6 years after left hip arthroscopy with labral repair. Detailed clinical measures and insight into potential risk factors are presented as a follow-up to a previously published case report.

OUTCOME

A 3.6-year follow-up assessment revealed potential risk factors that may have predisposed the subject to future pathology. The most profound finding was the subject's complaint of contralateral right hip pain and examination findings suggesting intraarticular pathology. His left surgical hip presented with no reported problems or significant findings. The examination also revealed an anterior tilted pelvis, muscle length deficits, and hip muscle weakness which may have contributed to his right hip pain or may be risk factors for future pathology in both hips. It appeared that these impairments affected his gait and performance on functional tests.

DISCUSSION

This case report describes the 3.6 year follow-up for a young adult male subject after unilateral left hip arthroscopy and acetabular labral repair. The re-examination findings and risk factors identified at the follow-up may provide insight into the need for long-term surveillance among post-surgical individuals. Detailed reporting of the long-term effects of a post-operative program after hip arthroscopy is non-existent in the literature and the current findings suggest the potential need for mitigating risk in the non-surgical hip. Future longitudinal studies are needed to develop a consensus on the best interventions for these patients.

LEVEL OF EVIDENCE

4-Case Report.

Efficacy of Hip Arthroscopy for the Management of Septic Arthritis: A Systematic Review

PURPOSE

This systematic review assessed the role of hip arthroscopic irrigation and debridement for eradication of infection in native joints to ascertain outcomes and complications associated with this surgical approach.

METHODS

The Medline, Embase, and PubMed databases were searched on July 20, 2014, for English-language studies that addressed arthroscopic treatment of native septic hip arthritis. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented.

RESULTS

There were 11 eligible studies (1 case-control study, 8 case series, and 2 case reports) reporting on 65 patients (65 hips) treated by arthroscopic irrigation and debridement for septic hip arthritis. The mean length of patient follow-up was 19.1 months (range, 6 to 84 months). The indications for surgery were as follows: pyrexia, anterior groin or hip pain with limited hip range of motion and an inability to bear weight, associated leukocytosis, an elevated erythrocyte sedimentation rate or C-reactive protein level, and/or hip imaging or aspiration results consistent with infection. Specific contraindications for surgery reported across studies included tuberculous of fungal infection, coexistence of osteomyelitis, immunocompromised individuals, and pre-existing surgery on the affected hip. The initial rate of infection eradication was 100%. All studies reported significant improvements in patient pain and function. Improvements were also observed in range of motion, as well as across both the Bennett radiographic and clinical assessments and Harris Hip Score. No complications, major or minor, were reported, and only 1 of 65 hips (1.5%) required revision arthroscopy for recurrence because of a methicillin-resistant Staphylococcus aureus infection.

CONCLUSIONS

Arthroscopic native hip irrigation and debridement for septic arthritis appear to comprise a safe and effective treatment option for selected patients (e.g., no deformity, no bacterial infections, and not immunocompromised). Timely diagnosis and intervention, however, remain the most critical prognostic factors for successful outcomes.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV and V studies.

Complications and survival analyses of hip arthroscopies performed in the national health service in England: a review of 6,395 cases

PURPOSE

Our study aimed to identify the complications of hip arthroscopies with particular emphasis on the 30-day readmission rate; 90-day deep vein thrombosis (DVT) and pulmonary embolism (PE) rate and mortality rate; revision hip arthroscopy rate; and in particular, survivorship with conversion to total hip replacement (THR) as the endpoint.

METHODS

The records of patients undergoing hip arthroscopy were extracted from the administrative hospital admissions database covering all admissions to the National Health Service hospitals in England using ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision) and OPCS-4 (Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures, fourth revision) codes.

RESULTS

A total of 6,395 hip arthroscopies were included in the study period. The 30-day readmission rate was 0.5%; both the 90-day DVT rate and PE rate were 0.08%; and the 90-day mortality rate was 0.02%. THR was performed in 680 patients (10.6%) at a mean of 1.4 years after the index operation, and 286 patients (4.5%) underwent revision hip arthroscopy at a mean of 1.7 years. Kaplan-Meier survival analysis showed an 8-year survival rate of 82.6% (95% confidence interval [CI], 80.9% to 84.2%), whereas Cox proportional hazard analysis adjusting for age, gender, and Charlson comorbidity score showed an 8-year survival rate of 86%. Female patients had a 1.68 times (95% CI, 1.41 to 2.01) higher risk of conversion to THR than male patients, and patients aged 50 years or older had a 4.65 (95% CI, 3.93 to 5.49) times higher risk of requiring hip replacement than patients younger than 50 years.

CONCLUSIONS

In this large series of 6,395 hip arthroscopies looking at the national data from the English National Health Service, our null hypothesis has been supported, and we have determined that the rate of short-term complications, in particular the risk of DVT and PE after this operation, is low. Higher age and female gender are significant predictors of conversion to THR, with Cox proportional hazard analyses showing a survivorship rate of 86% at 8 years after adjustment for confounding variables.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Return to sport after hip surgery for femoroacetabular impingement: a systematic review

BACKGROUND

We aimed to appraise (1) the rate of return to sport of athletes after hip surgery for femoroacetabular impingement (FAI) and (2) some aspects that may influence the return to sport.

METHODS

Four databases (EMBASE, PubMed, Web of Science, Cochrane Library) were searched until 21 October 2014. Studies evaluated return to sport of athletes who underwent hip surgery for the treatment of symptomatic FAI. A validated tool was used for quality evaluation of the studies.

RESULTS

A total of 18 case series (level of evidence IV) with moderate-to-high methodological quality were included. On average, 87% of athletes returned to sport after hip surgery for FAI and 82% returned to the same sport level as before the occurrence of the symptoms. Professional athletes seem to return to sport at a higher rate compared with recreational and collegiate athletes. Sport participation after hip arthroscopy tends to decrease for professional athletes at short-term and mid-term follow-ups. Diffuse hip osteoarthritis at the time of surgery may not allow athletes to return to sport.

CONCLUSIONS

Most athletes return to sport after hip surgery for the treatment of symptomatic FAI. The level of competition, time of evaluation after hip surgery and presence of articular cartilage lesions at the time of surgery may influence return to sport. Future studies with higher levels of evidence should describe and evaluate return to sport protocols after hip surgery for FAI.

A multi-centre randomized controlled trial comparing arthroscopic osteochondroplasty and lavage with arthroscopic lavage alone on patient important outcomes and quality of life in the treatment of young adult (18-50) femoroacetabular impingement

BACKGROUND

Several cross-sectional studies have estimated that the prevalence of femoroacetabular impingement (FAI) ranges from 14-17% among asymptomatic young adults to almost 95% among competitive athletes. With FAI, there is abnormal contact between the proximal femur and the acetabulum, resulting in abnormal mechanics with terminal motion such as hip flexion and rotation. This condition results from bony anomalies of the acetabular rim (Pincer) and or femoral head/neck junction (CAM) and typically causes hip pain and decreased hip function. The development of hip pain potentially serves as an indicator for early cartilage and labral damage that may result in hip osteoarthritis. Although surgical correction of the misshaped bony anatomy and associated intra-articular soft tissue damage of the hip is thought to improve hip pain and alter the natural history of degenerative disease, the supportive evidence is based upon low quality observational studies. The Femoroacetabular Impingement RandomiSed controlled Trial (FIRST) compares outcomes following surgical correction of the impingement morphology (arthroscopic osteochondroplasty) with/without labral repair versus arthroscopic lavage of the hip joint in adults aged 18 to 50 diagnosed with FAI.

METHODS AND DESIGN

FIRST is a multi-centre, randomized controlled trial with a sample size of 220 patients. Exclusion criteria include the presence of hip syndromes, previous surgery or trauma to the affected hip, and significant medical comorbidities. The primary outcome is pain and the secondary outcomes include patient function, quality of life, complications, and cost-effectiveness--all within one year of follow-up. Patients are stratified based on centre and impingement sub-type. Patients, outcome assessors, data analysts, and the Steering Committee are blinded to surgical allocation. Using an intention-to-treat approach, outcome analyses will be performed using an analysis of covariance and descriptive statistics.

DISCUSSION

Symptomatic FAI is associated with chronic hip pain, functional limitations, and secondary osteoarthritis. Therefore, optimizing treatment has the potential to improve the lives millions of young, active persons who are diagnosed with this condition. Few orthopaedic surgical trials have similar potential to shift the paradigm of care dramatically towards (or away) from surgical bony and soft tissue interventions.

TRIAL REGISTRATION

The FIRST trial is registered with clinicaltrials.gov (NCT01623843).

Femoroacetabular impingement surgery: are we moving too fast and too far beyond the evidence?

Femoroacetabuler impingement (FAI) is becoming increasingly recognised as a potential pathological entity for individuals with hip pain. Surgery described to correct FAI has risen exponentially in the past 10 years with the use of hip arthroscopy. Unfortunately, the strength of evidence supporting both the examination and treatment of FAI does not appear to accommodate this exponential growth. In fact, the direction currently taken for FAI is similar to previously described paths of other orthopaedic and sports medicine pathologies (eg, shoulder impingement, knee meniscus tear) for which we have learned valuable lessons. The time has come for improved terminology, study design, and focus on delineation of successful treatment variables in the interest of those individuals with clinical indications of FAI so that we can appropriately address their needs.

Femoroacetabular impingement in skeletally immature patients: a systematic review examining indications, outcomes, and complications of open and arthroscopic treatment

PURPOSE

Improvements in physical examination and radiographic appreciation of symptomatic femoroacetabular impingement (FAI) has increased the focus on early diagnosis and treatment in an adolescent population. This systematic review aimed to establish specific indications, outcomes, and complications of surgical management of adolescent FAI.

METHODS

The Medline, Embase, and PubMed online databases were searched from inception until April 21, 2014, for English-language studies that addressed open and/or arthroscopic treatment of FAI in patients aged 10 to 19 years inclusively. The studies were systematically screened and data abstracted in duplicate, with qualitative findings presented.

RESULTS

There were 6 eligible case series (4 with arthroscopic and 2 with open technique) and 2 conference abstracts examining 388 patients in total (435 hips), 81% of which were treated with hip arthroscopy. Overall, patients were followed up for a mean of 23.4 months postoperatively (range, 3 to 75 months). The main indication for surgery was a confirmed diagnosis of FAI with persistent pain and impaired function refractory to nonoperative interventions (activity modification, intra-articular injections, and so on). Specific contraindications included Tönnis grade 2, 3, or 4 chondral changes and acetabular dysplasia. All studies reported significant improvements in patient pain, function (e.g., no patients were "abnormally" or "severely abnormally" impaired), and satisfaction rates (84% to 100% with arthroscopic technique v 79% with open technique). Improvements also were observed in range of motion and alpha angle correction, as well as across a variety of patient-reported functional scores, with all but 7 of 388 patients (1.8%) returning to activity/sport. No major complications were reported, with only 13 of 354 hips (3.7%) treated by arthroscopy requiring revision arthroscopy for lysis of adhesions and 1 of 81 open surgical dislocation hips (1%) having asymptomatic heterotopic ossification not requiring additional management. No cases of avascular necrosis, physeal arrest or growth disturbance, or iatrogenic deformity were reported.

CONCLUSIONS

Both arthroscopic and open surgical dislocation approaches for the treatment of adolescent FAI appear to be safe and effective options for patients with persistent pain and limited function after an appropriate trial of nonoperative therapy.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review

BACKGROUND

This is a systematic review to determine if prophylactic surgical intervention for asymptomatic patients with radiographic evidence of femoroacetabular impingement (FAI) is warranted to prevent early degenerative joint disease of the hip.

METHODS

A systematic search was performed from 1965 to 2013 in PubMed and EMBASE. Inclusion criteria were prospective or retrospective studies comparing skeletally mature asymptomatic patients with radiographic evidence of FAI treated with prophylactic hip arthroscopic surgery versus nonoperative management. A total of 840 references were identified from the searches. After detailed eligibility screening, none of the references met the eligibility criteria.

RESULTS

No trials were identified that met the criteria for inclusion in the review.

CONCLUSION

There is a lack of available evidence to support surgical intervention for the treatment of FAI in asymptomatic patients. This article attempts to address this dilemma by reviewing the available literature to answer several questions that would indirectly address the topic. First, what is the prevalence of FAI in the asymptomatic population? Second, what is the natural history of FAI if left untreated? Upon reviewing these issues, the authors' conclusion parallels that of the systematic review: Current evidence does not support prophylactic surgery for asymptomatic FAI in the vast majority of cases. However, limited evidence suggests that asymptomatic patients who have previously undergone total hip arthroplasty for FAI-induced osteoarthritis of the contralateral hip are at a significantly increased risk for early degenerative joint disease. Further research is needed to better clarify surgical indications.

Protocol for the Femoroacetabular Impingement Trial (FAIT): a multi-centre randomised controlled trial comparing surgical and non-surgical management of femoroacetabular impingement

AIMS

Femoroacetabular Junction Impingement (FAI) describes abnormalities in the shape of the femoral head-neck junction, or abnormalities in the orientation of the acetabulum. In the short term, FAI can give rise to pain and disability, and in the long-term it significantly increases the risk of developing osteoarthritis. The Femoroacetabular Impingement Trial (FAIT) aims to determine whether operative or non-operative intervention is more effective at improving symptoms and preventing the development and progression of osteoarthritis.

METHODS

FAIT is a multicentre superiority parallel two-arm randomised controlled trial comparing physiotherapy and activity modification with arthroscopic surgery for the treatment of symptomatic FAI. Patients aged 18 to 60 with clinical and radiological evidence of FAI are eligible. Principal exclusion criteria include previous surgery to the index hip, established osteoarthritis (Kellgren-Lawrence ≥ 2), hip dysplasia (centre-edge angle < 20°), and completion of a physiotherapy programme targeting FAI within the previous 12 months. Recruitment will take place over 24 months and 120 patients will be randomised in a 1:1 ratio and followed up for three years. The two primary outcome measures are change in hip outcome score eight months post-randomisation (approximately six-months post-intervention initiation) and change in radiographic minimum joint space width 38 months post-randomisation. ClinicalTrials.gov: NCT01893034. Cite this article: Bone Joint Res 2014;3:321-7.

An anatomical study of the acetabulum with clinical applications to hip arthroscopy

BACKGROUND

The clock face has been employed to define the position of labral pathology in relation to identifiable arthroscopically relevant acetabular landmarks. The purpose of this study was to qualitatively and quantitatively describe arthroscopically relevant anatomy of the acetabulum. We aimed to present a surgical landmark that is located in close proximity to the usual location of labral pathology as an alternative to the midpoint of the transverse acetabular ligament as a reference point.

METHODS

Fourteen fresh-frozen cadaveric hemipelves were dissected to evaluate osseous landmarks and relevant surrounding soft-tissue structures of the acetabulum. With use of a coordinate-measuring device, we determined the location, orientation, and relationship of key arthroscopic landmarks and the footprint areas formed by the insertions of the rectus femoris, capsule, and labrum.

RESULTS

An analysis of variability of reference points around the acetabulum in relation to the anterior inferior iliac spine (AIIS) revealed that the superior margin of the anterior labral sulcus (psoas-u) was the most consistent anatomic landmark. The AIIS comprised superior and inferior facets, demarcated by the origins of the direct head of the rectus femoris and the iliocapsularis. The inferolateral corner of the footprint of the direct head of the rectus femoris was located 19.2 mm (95% confidence interval [CI], 18.0 to 20.4 mm) from the acetabular rim and the inferolateral aspect of the iliocapsularis footprint, 12.5 mm (95% CI, 10.1 to 15.0 mm) from the rim.

CONCLUSIONS

The superior margin of the anterior labral sulcus (psoas-u) was a reliable landmark for reference of the clock face on the acetabulum. We propose that this point, denoting 3:00, be adopted as the new standard clock-face reference for intra-articular hip structures because of its universal presence and reliable arthroscopic visualization. This marker is also beneficial because of its proximity to the typical location of labral pathology. The data presented provide a comprehensive analysis of pertinent arthroscopically relevant acetabular anatomy.

CLINICAL RELEVANCE

The establishment of a new standard reference point within the acetabulum will enhance the consistency of interpretation of the location of labral pathology and improve arthroscopic orientation and navigation.

The role of hip arthroscopy in the management of osteonecrosis

Hip arthroscopy has emerged as a diagnostic and therapeutic tool in the management of osteonecrosis (ON) of the femoral head. Direct visualization of the joint, aids the staging of the disease, while mechanical symptoms and pain can be alleviated by addressing the often coexisting intra-articular pathology (labral tears, chondral delamination, loose bodies and synovitis) thereby improving the clinical outcome in some patients. The article explores the role and possible value of hip arthroscopy as a surgical technique in the treatment of hip ON.

A less-invasive technique for capsular management during hip arthroscopy for femoroacetabular impingement

The aim of this work is to describe a new arthroscopic technique for the treatment of femoroacetabular impingement that allows a complete articular joint view with maximum protection of the capsuloligamentous complex. This arthroscopic technique avoids injury to the capsuloligamentous complex, preventing the risk of postoperative instability. The diagnosis of femoroacetabular impingement was based on clinical and radiographic grounds. An alpha angle greater than 50° was considered pathologic. In this technique, the use of intra-articular devices (retractors) allows us to separate the capsular tissue from the femoral head-neck junction and mobilize the capsule, achieving an adequate joint view without performing a capsulotomy and, consequently, avoiding the complications of capsular damage.

Alpha angle correction in femoroacetabular impingement

PURPOSE

The predictive value of the alpha angle, currently the most validated magnetic resonance imaging parameter for CAM-impingement FAI, remains to be systematically evaluated in the orthopaedic literature. A systematic review was conducted to determine whether alpha angle correction influences clinical outcomes in patients with FAI.

METHODS

We searched three databases (MEDLINE, EMBASE and PubMed) for English clinical studies published up to August 2012, reporting surgical correction of the alpha angle in patients with a primary diagnosis of FAI. Two independent assessors reviewed eligible studies. Where applicable, the Newcastle-Ottawa Scale was used to perform a quality assessment. Descriptive statistics are presented.

RESULTS

Of the 1,103 studies initially retrieved, 14 fulfilled our eligibility criteria. Majority of studies (86 %) were case-control designs, with no randomized controlled trials. Variability existed in the surgical techniques and modalities used to measure pre- and post-operative alpha angles. All 14 studies reported a mean measured post-operative restoration of a normal alpha angle (equal to or less than 55°). Failure due to inadequate osseous correction was cited in 3/14 included studies. Correction resulted in significant improvements in range of motion and patient Visual Analog Scales, non-arthritic hip scores, Harris Hip Scores and the short-form-12.

CONCLUSION

Based on this review, there is evidence supporting that precise surgical restoration of the alpha angle in CAM-type FAI to a minimum of less than 55° will lead to improved patient outcomes. The alpha angle is a good predictor of outcome and represents a simple, reproducible and inexpensive guide that can be used intra-operatively and post-operatively.

Hip arthroscopy: less invasive technique

The popularity of hip arthroscopy has increased significantly over the past decade. It is technically demanding and may be associated with complications such as iatrogenic damage to the articular cartilage or acetabular labrum, compression injuries to the structures in the perineum, and distraction injuries to the leg. Some of these complications can be avoided by paying meticulous attention to the technique and reducing the traction/surgical time. We describe a technique by which the risk of injury to the articular cartilage may be minimized by introduction of the surgical instruments under direct vision, rather than under radiologic control. The described technique is likely to reduce the operating time by addressing the peripheral-compartment pathologies first-without traction. Traction is only required for the central-compartment procedures. Exposure to ionizing radiation is also diminished (eliminated with practice) because the portals are established under direct vision of the arthroscopist.

Surgical treatment of femoroacetabular impingement: what are the limits of hip arthroscopy?

The variety of hip pathology that can be addressed in a minimally invasive fashion in the young, pre-arthritic patient has rapidly grown in parallel with technical advances in hip arthroscopy. However, the indications and limits of arthroscopy must be carefully defined and indications must evolve correspondingly to avoid an increase in failure rates and unsatisfactory clinical outcomes. Some diagnoses may be better and more comprehensively addressed with open procedures or combined surgical approaches. The purpose of this article is to provide an unbiased and evidence-based review of conditions of the pre-arthritic hip to define our current understanding of the advantages, disadvantages, and limitations of an arthroscopic approach.

Preventing falls in the operating room: a technique tip for safely tilting the operating table

BACKGROUND

Many articles have been published to address the topic of in-hospital falls; however, there is considerably less literature that focuses specifically on the topic of falls from the operating room table. The lay press and legal filings contain reports of such incidents, which can result in considerable morbidity, lawsuits, and occasional death.

TECHNIQUE

When tilting the operating table, a simple technique for preventing falls is through the use of posts. Posts are regularly used during knee and hip arthroscopy to facilitate valgus positioning or access into the joint. These posts can be positioned below the axilla and at the level of the greater trochanter to supplement patient safety straps when tilting the table.

DISCUSSION

Falls that occur during a hospital admission can lead to serious injury and prolonged hospital stays. Furthermore, falls that occur off the operating table are particularly disastrous and in some cases have resulted in death. Our proposed technique is simple and particularly useful for patients with large or small body habitus or when operating procedures necessitate significant tilting of the operating table.

LEVELS OF EVIDENCE

Level V.