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

Iatrogenic "overshoot" nerve injuries: imaging features

OBJECTIVE

Describe features of iatrogenic "overshoot" nerve injuries on ultrasound and MRI, which occur when an instrument passes through the bone and injures the nerve after it penetrates the opposite cortex.

MATERIALS AND METHODS

After a keyword search of the radiology database at a tertiary care orthopedic hospital from January 2016 to December 2022, those fulfilling the inclusion criteria of (1) instrumentation through the bone during surgery, (2) acute neuropathy immediately after surgery, (3) nerve injury confirmed on electrodiagnostics, and (4) imaging consistent with overshoot nerve injury were included. Imaging studies were retrospectively evaluated to determine primary and secondary signs of an overshoot nerve injury.

RESULTS

Six patients (3 females, mean age 26.7 (range 10-49) years) had nerve injury fitting the mechanism of injury: 3 injuries to the radial nerve during fixation of distal humerus fractures, 1 tibial nerve and 1 superficial peroneal nerve injury during fixation of tibial fractures, and 1 posterior interosseous nerve injury during biceps tendon repair. Ultrasounds were performed in all while 4 also had MRI. Secondary signs included (1) cortical defect adjacent to injured nerve (n=2); (2) scar extending from bone to injured nerve (n=2); (3) screw tip pointing to injured nerve (n=1, 4) tract in bone on MRI from previous instrumentation pointing to injured nerve (n=2).

CONCLUSION

In addition to primary signs such as laceration or neuroma, secondary signs of "overshoot" nerve injury include cortical defect, scar extending to nerve, screw tip pointing to nerve, and linear tract in the bone on MRI.

Patients Undergoing Postless Hip Arthroscopy Demonstrate Significantly Better Patient-Reported Outcomes and Clinically Significant Outcomes Compared to Conventional Post-Assisted Hip Arthroscopy at Short-Term Follow-Up

PURPOSE

To prospectively compare the short-term clinical outcomes of patients undergoing hip arthroscopy with versus without the use of a perineal post.

METHODS

A prospective, single-surgeon cohort study was performed on a subset of patients undergoing hip arthroscopy between 2020 and 2022. A post-free hip distraction system was used at 1 center at which the senior author operates, and a perineal post was used at another surgical location. An electronic survey of patient-reported outcome measures (PROMs) was completed by each patient at a minimum of 1 year postoperatively. PROMs included a visual analog scale for pain; University of California, Los Angeles (UCLA) Activity Scale; modified Harris Hip Score (mHHS); Hip Outcome Score-Sports-Specific Subscale (HOS-SSS); and a Single Assessment Numeric Evaluation. Postoperative scores and clinically significant outcomes, including the minimal clinically important difference, substantial clinical benefit, and patient acceptable symptom state, for each PROM were compared between groups.

RESULTS

Sixty-nine patients were reached for follow-up (41 post, 28 postless) of 87 patients eligible for the study (79%). No significant differences were found between groups in terms of sex (post: 61% female, postless: 54% female, P = .54), age (post: 34 years, postless: 29 years, P = .11), body mass index (post: 26, postless: 24, P = .23), or follow-up duration (post: 24.4 months, postless: 21.3 months, P = .16). There was a significantly higher visual analog scale (3.1 vs 1.4, P = .01), a significantly lower UCLA Activity Scale score (7.0 vs 8.4, P = .02), and a significantly lower mHHS (73.7 vs 82.2, P = .03) in the post-assisted group. A significantly higher proportion of patients in the postless group achieved a patient acceptable symptom state for the UCLA (89.3% vs 68.3%, P = .04), mHHS (84.6% vs 61.0%, P = .04), and HOS-SSS (84.0% vs 61.0%, P = .048) and a substantial clinical benefit for HOS-SSS (72.0% vs 41.5%, P = .02). One patient (2.6%) in the post group underwent revision hip arthroscopy, and another was indicated for total hip arthroplasty by the time of follow-up.

CONCLUSIONS

Postless hip arthroscopy may result in better clinical outcomes compared with post-assisted hip arthroscopy.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

A High Incidence of Perineal Post-Related Complications After Hip Arthroscopy Is Self-Reported by Patients in Anonymous Online Forums

Purpose

To evaluate online, self-reported pudendal nerve or perineal injuries related to the use of a perineal post during hip arthroscopy.

Methods

Public posts on Reddit and the Health Organization for Pudendal Education were searched to identify anonymous individuals reporting symptoms of pudendal nerve or perineal injury following hip arthroscopy. Included posts were by any individual with a self-reported history of hip arthroscopy who developed symptoms of pudendal nerve injury or damage to the perineal soft tissues. Demographic information and details about a person's symptoms and concerns were collected from each post. Descriptive statistics were used to analyze the data.

Results

Twenty-three online posts reported on a perineal post-related complication following hip arthroscopy. Sex information was available in 16 (70%) posts (8 male, 8 female). Twenty-two posts reported a sensory injury, and 4 posts reported a motor injury with sexual consequences (sexual dysfunction, dyspareunia, impotence). Symptom duration was available in 15 (65%) posts (8 temporary, 7 permanent). Permanent symptoms included paresthesia of the perineum or genitals (7) and sexual complaints (5). Two posts stated they were counseled preoperatively about the possibility of this injury. Zero patients reported that a postless hip arthroscopy alternative was an option made available to them before surgery.

Conclusions

A high incidence of permanent pudendal nerve, perineal skin, and genitourinary/sexual complications are self-reported and discussed online by patients who have undergone post-assisted hip arthroscopy. These patients report being uninformed and undereducated about the possibility of sustaining a post-related complication. No patient reported being informed of postless hip arthroscopy preoperatively.

Clinical Relevance

Identifying and evaluating self-reported patient information in online medical forums can provide important information about patient experiences and outcomes.

T, Maniar A, Mitrasinovic S, Menta SV, Ranawat A. Intraoperative traction has a negligible time-dependent influence on patient-reported outcomes after hip arthroscopy: a cohort study

The aim of this study is to determine if post-operative patient-reported outcome measures (PROMs) are influenced by hip arthroscopy traction duration. Patients from a local prospective hip arthroscopy database were retrospectively analyzed. Four hip-specific PROMs were utilized: modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS), and international Hip Outcome Tool (iHOT). PROMs were collected pre-operatively and 6 months, 1 year and 2 years post-operatively. Two cohorts were created based on a cut-off corresponding to the 66th percentile for our patient cohort. Analyses were completed for each PROM at each post-operative interval with univariable statistics. Multivariable statistics were examined to identify the variables that were predictive of achieving post-operative minimal clinically important difference (MCID) at the 2-year follow-up. Overall, 222 patients met the inclusion criteria. The mean age was 32.4 ± 9.4 years, and 116 (52.3%) were female. The average traction time of the study population was 46.1 ± 12.9 min. A total of 145 patients were included in the short traction cohort (65%) with traction times of <50 min (66th percentile). No significant differences were found regarding PROM scores or MCID achievement rates between both cohorts at any post-operative period. In multivariable analyses, achievement of MCID was predicted by a decrease in traction time for all PROMs and pincer-type resection for mHSS, HOS-ADL and iHOT. There was no difference in PROMs and MCID achievement between longer and shorter traction time cohorts. On multivariable analysis, a decrease in traction time is predictive of MCID for all PROM scores and pincer-type resection was predictive of MCID for most PROM scores. Level of evidence: Level III, cohort study.

Better sex after hip arthroscopy; Sexual dysfunction in patients with femoro-acetabular impingement syndrome

BACKGROUND

Femoro-acetabular impingement syndrome (FAIS) is a common cause of hip pain and functional decline. The quality of life of affected patients has been shown to be significantly diminished, with potential alterations in the ability to perform activities of daily living and recreation, including sexual function. Hip arthroscopy is the surgical technique recognized as the gold standard in FAIS. The aim of this study was to research the relationship between hip arthroscopy due to FAIS and pre- and postoperative sexual function.

HYPOTHESIS

The hypothesis of the study was that sexual dysfunction would be common during the preoperative period but would significantly improve after surgery.

MATERIALS AND METHODS

This retrospective study included 96 patients aged 18 to 55 years, who underwent hip arthroscopy for a FAIS diagnosis between 2015 and 2021, with a minimum follow-up of one year. Exclusion criteria were a bilateral symptomatic hip condition, history of ipsilateral hip or knee surgery, history of urological or gynecological conditions, sexual dysfunction, or a history of hip osteonecrosis or osteoarthritis. The Female Sexual Function Scale (FSFI) was used to evaluate sexual dysfunction in females and the International Erectile Function Index (IIEF-5) for males.

RESULTS

The patients comprised 56.3% males and 43.82% females with a mean age of 35.3±8.3 years. Sexual dysfunction was determined preoperatively in 85.2% of the males and in 57.1% of the females. Overall improvement after surgery was statistically significant. Signs of pudendal nerve damage were seen during the postoperative period in 29 (30.2%) patients. The change in total sexual scores was significantly correlated with nerve symptoms and regression analysis showed that traction time was a significant risk factor for pudendal nerve symptoms.

DISCUSSION

Sexual dysfunction is a common trait of patients suffering from FAIS and the majority of patients significantly benefit from the procedure. Sexual dysfunction persists in a category of patients during the postoperative period, regardless of the type of lesion, and this phenomenon is associated with transient pudendal nerve symptoms, which are more likely to occur with longer traction times and thus represent a clear risk factor.

LEVEL OF EVIDENCE

IV.

Traction-related complications in hip arthroscopy for 26 years. A systematic review

The primary aim of the study is to determine the rate of traction-related complications in hip arthroscopy (HA) including perineal compression and distraction injuries, and the secondary objective is to report the incidence of complications in HA found on the studies selected by a systematic review. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used for data extraction from the PubMed and Cochrane databases obtained in February 2022. Reviewers extracted the title, author, date of publication, number of hips treated and number of complications describing the affected area, nerve and soft tissue injury related to traction. Studies on postless HA and HA combined with other procedures were excluded. Twenty-six years of HA literature was found in the search that included 35 studies and 8126 hips (89% Level IV) that reported the complications found during the procedure and described complications related to traction. A total of 623 hips (7.7%) had some sort of complications during HA, and complications related to traction were in 227 hips (36%). Injuries caused specifically by the perineal compression were in 144 hips (23%) that included the pudendal nerve and soft tissue injury of the groin area. Complications caused by the distraction were in 83 hips (13%) that included sciatic and peroneal nerve injury, numbness or pain of ankle and foot. HA complications occurred in 7.7% of hips treated, which is found in this systematic review. One-third of the complications are related to traction, 23% are caused by perineal compression and 13% are caused by distraction.

Are complications related to the perineal post on orthopaedic traction tables for surgical fracture fixation more common than we think? A systematic review

BACKGROUND

Traction tables have long been utilized in the management of fractures by orthopaedic surgeons. The purpose of this study was to systematically review the literature to determine the complications inherent to the use of a perineal post when treating femur fractures using a traction table.

METHODS

A systematic review was conducted using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) using PubMed, EMBASE, and Cochrane Library. The search phrase used was "fracture" AND "perineal" AND "post" AND ("femur" OR "femoral" OR "intertrochanteric" OR "subtrochanteric"). Inclusion criteria for this review were: level of evidence (LOE) of I - IV, studies reporting on patients surgically treated for femur fractures, studies reporting on patients treated on a fracture table with a perineal post, and studies that reported the presence or absence of perineal post-related complications. The rate and duration of pudendal nerve palsy were analyzed.

RESULTS

Ten studies (2 prospective and 8 retrospective studies; 2 LOE III and 8 LOE IV) were included consisting of 351 patients of which 293 (83.5%) were femoral shaft fractures and 58 (16.5%) were hip fractures. Complications associated with pudendal nerve palsies were reported in 8 studies and the mean duration of symptoms ranged between 10 and 639 days. Three studies reported a total of 11 patients (3.0%) with perineal soft tissue injury including 8 patients with scrotal necrosis and 3 patients with vulvar necrosis. All patients that developed perineal skin necrosis healed through secondary intention. No permanent complications relating to pudendal neurapraxia or soft tissue injuries were reported at final follow-up timepoints.

CONCLUSION

The use of a perineal post when treating femur fractures on a fracture table poses risks for pudendal neurapraxia and perineal soft tissue injury. Post padding is mandatory and supplemental padding may also be required. Appropriate perineal skin examination prior to use is also important. Occurring at a higher rate than previously thought, appropriate post-operative examination for any genitoperineal soft tissue complications and sensory disturbances should not be ignored.

Editorial Commentary: Minimizing Traction Force and Time as Well as Application of Specific Technical Pearls Might Trump the Importance of Choosing Between Post or Postless Hip Arthroscopy With Regards to Complications

Recently, there has been a trend toward performing hip arthroscopy without a post (postless) in an effort to decrease perineal post-related complications. Previous studies have revealed a variable risk of pudendal nerve neuralgia and perineal soft-tissue injury when using a post. There is emerging evidence that arthroscopic hip procedures can be done without the use of a post, with less traction force on the perineal region, and with adequate exposure to safely accomplish a well-done femoroacetabular impingement corrective procedure. Prospective comparative studies with conclusive evidence of the superiority of either technique, however, are lacking. Complications with a post are likely associated with high traction forces, prolonged traction times, and potentially suboptimal technique and patient positioning. In addition, postless traction is in its infancy and new adverse events/outcomes are likely to emerge. There are likely specific situations and patient populations in which one technique might be superior to the other. We are the carpenters of medicine and rather than blaming our tools and throwing out a technique that has served us well for decades, we should better understand some important pearls and pitfalls that might allow either method to be safely performed.

A Prospective Comparison of Groin-Related Complications After Hip Arthroscopy With and Without a Perineal Post

BACKGROUND

Previous studies have demonstrated various groin-related nerve and soft tissue complications in patients undergoing hip arthroscopy with a perineal post.

PURPOSE

To prospectively compare groin-related nerve and soft tissue complications between patients undergoing hip arthroscopy with and without the use of a perineal post.

STUDY DESIGN

Cohort study; Level of evidence, 2.

METHODS

A prospective single-surgeon cohort study was performed on all patients undergoing hip arthroscopy by the senior author between January 2020 and March 2022. A post-free hip distraction system was used at 1 center in which the senior author operates, and a system with a large padded perineal post was used at another surgical location. Patients completed a survey at the first postoperative visit (7-10 days) to determine if they had experienced any groin-related complications after surgery (groin numbness, sexual/urinary dysfunction, skin tears). Patients with a positive survey response repeated the survey at each follow-up visit (6 weeks, 3 months, 6 months) until the symptoms resolved. The rate and duration of groin-related complications were then compared between the groups.

RESULTS

A total of 87 patients were included in the study who underwent hip arthroscopy: 53 with a perineal post and 34 without. No differences were found between the post and postless groups in terms of age at surgery, sex, body mass index, or traction time. We found that 16 patients (30%) in the perineal post group experienced groin numbness versus 0 (0%) in the postless group (P < .0001). On average, groin numbness lasted 5 ± 3 days (mean ± SD) in the perineal post group. Three patients in the perineal post group experienced sexual dysfunction for a mean 7 days, as compared with none in the postless group. Seventeen patients (32%) in the perineal post group experienced foot numbness versus 4 (12%) in the postless group (P = .04). One patient in the perineal post group reported a superficial skin tear.

CONCLUSION

Postless hip arthroscopy resulted in no risk of groin-related complications as compared with traditional hip arthroscopy with a perineal post.

Current Trends in the Use of Postless Hip Arthroscopy: A Survey of the International Society for Hip Arthroscopy Membership

Background

Previous studies have demonstrated the risks of pudendal nerve and/or soft tissue complications due to the use of a perineal post during hip arthroscopy. Recently, various postless hip arthroscopy techniques have been described in the literature.

Purpose

To assess the current international trends in the use of postless hip arthroscopy among hip preservation specialists.

Study Design

Cross-sectional study.

Methods

An anonymous 11-item survey was sent by email to all members of the International Society for Hip Arthroscopy (ISHA) in January 2022. Surgeons were asked various questions regarding their current use of post-assisted or postless hip arthroscopy, if they had changed their setup technique during their career and the reason for that change, and their perceived rate of pudendal nerve and/or perineal soft tissue injuries using their current technique. Descriptive statistics were used to report the results of each question. The Student t test was used to compare the number of years in practice between post-assisted and postless users. Fisher exact tests were performed to compare categorical rates of pudendal nerve and soft tissue complications between post-assisted and postless users.

Results

A total of 126 surveys were completed from 431 ISHA members (29.2%). Sixty-one percent of the surgeons currently use a perineal post, while 33% use a postless technique. Seventy-five percent of the perineal post users and 98% of the postless users self-reported a rate of pudendal nerve and/or soft tissue injury of <1% (P = .015). Among 41 respondents who indicated changing their technique at some point, 59% reported doing so because of pudendal nerve and/or soft tissue complications. Among surgeons who switched from a perineal post to a postless setup, 71% indicated they have noticed a decrease in the rate of pudendal nerve and/or soft tissue complications.

Conclusion

Although use of a perineal post is still a more common setup technique among hip arthroscopists, approximately one-third of surgeons use a postless technique. Surgeons who have switched to a postless technique often did so because of perineal complications, with the majority noticing a subjective decrease in these complications with the use of postless hip arthroscopy.

Postless Arthroscopic Hip Preservation Can be Adequately Performed Using Published Techniques

Purpose

To identify and evaluate techniques used for postless hip arthroscopy.

Methods

A narrative review was performed using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify surgical technique articles or clinical studies describing techniques for the use of postless hip arthroscopy. Specific items sought for analysis included hip arthroscopy for femoroacetabular impingement including cam or pincer-type lesions, surgical time, traction time, traction force, bed Trendelenburg angle, intraoperative techniques, and postoperative outcomes, including complications. Exclusion criteria included any postless techniques used for open hip surgeries such as periacetabular osteotomy, sports hernia, peritrochanteric work, gluteus medius repair, ischiofemoral impingement, hamstring repair, or need for intraoperative conversion from postless to posted technique.

Results

Ten studies (1 Level III, 3 Level IV, 6 Level V), published from 2007 to 2021, were analyzed (1,341 hips, 51.5% male, mean age ranged from 16.0 to 66.0 years). In 4 studies, Trendelenburg position with a foam pad (The Pink Pad; Xodus Medical, Inc.) was used at 5 to 20°. Six of 10 studies contained no clinical results. The average traction force and time ranged from 65.0 to 88 pounds and 31.0 to 73.5 minutes, respectively. The remaining studies used the yoga mat technique, the Tutankhamun technique, the beanbag technique, and the Hip Arthroscopy Post-less Procedure Impingement technique. There was only one incident of pudendal neurapraxia, which resolved spontaneously at 6 weeks without complication. Sufficient distraction was able to be obtained using postless traction in all cases.

Conclusions

Postless hip arthroscopy may adequately be performed with a variety of techniques. Obtaining adequate traction and countertraction may be achieved through these postless methods.

Clinical Relevance

Given the potential serious complications that may result from use of a perineal post, it is important for surgeons to be aware of postless techniques that may be used effectively for hip arthroscopy.

Pudendal Neurapraxia After Proximal Hamstring Repair: A Case Report

CASE

The pudendal nerve lies near the origin of the hamstring muscles, placing it at increased risk of injury during proximal hamstring tendon repair. In this study, we report on a 56-year old man who experienced intermittent unilateral testicular pain after a proximal hamstring tendon repair presumably due to pudendal nerve neurapraxia. At the 1-year follow-up, he continued to experience discomfort in the pudendal nerve distribution but reported significant improvement in symptoms and complete resolution of hamstring pain.

CONCLUSION

Although the risk of pudendal nerve injury during proximal hamstring tendon repair is rare, surgeons should be aware of this potential complication.

Editorial Commentary: Differences in Femoral Torsion Measurements Based on Axial Versus Axial-Oblique Magnetic Resonance Imaging Sequences-Let's Begin to Standardize Hip-Preservation Techniques to Improve Research and Clinical Outcomes

Femoral torsion is an important measure in patients with femoroacetabular impingement presenting with limited hip range of motion. However, femoral torsion may be measured using computed tomography or magnetic resonance imaging and on axial or axial-oblique sequences. Recent research shows that femoral torsion measurements differ based on the magnetic resonance imaging sequences on which this parameter is measured. In some cases, this may be clinically relevant in the sense that a derotational femoral osteotomy may be considered when otherwise it would not be. As more research is published within the specialized field of hip preservation surgery, we must begin to standardize our research and clinical techniques such that outcomes may be appropriately compared across studies.

Pre- and intraoperative decision-making challenges in hip arthroscopy for femoroacetabular impingement

There has been a marked increase in the number of hip arthroscopies performed over the past 16 years, primarily in the management of femoroacetabular impingement (FAI). Insights into the pathoanatomy of FAI, and high-level evidence supporting the clinical effectiveness of arthroscopy in the management of FAI, have fuelled this trend. Arthroscopic management of labral tears with repair may have superior results compared with debridement, and there is now emerging evidence to support reconstructive options where repair is not possible. In situations where an interportal capsulotomy is performed to facilitate access, data now support closure of the capsule in selective cases where there is an increased risk of postoperative instability. Preoperative planning is an integral component of bony corrective surgery in FAI, and this has evolved to include computer-planned resection. However, the benefit of this remains controversial. Hip instability is now widely accepted, and diagnostic criteria and treatment are becoming increasingly refined. Instability can also be present with FAI or develop as a result of FAI treatment. In this annotation, we outline major current controversies relating to decision-making in hip arthroscopy for FAI. Cite this article: Bone Joint J 2022;104-B(5):532-540.

Post-Related Complications in Hip Arthroscopy Are Reported Significantly Greater in Prospective Versus Retrospective Literature: A Systematic Review

PURPOSE

To determine whether there are differences in (1) the incidence of post-related complications following hip arthroscopy between prospective and retrospective publications; and (2) between post-assisted and postless techniques.

METHODS

A systematic review was performed using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines to characterize post-related complications following hip arthroscopy for central or peripheral compartment hip pathology, including femoroacetabular impingement syndrome and chondrolabral injury. Inclusion criteria were prospective and retrospective Level I-IV evidence investigations that reported results of hip arthroscopy performed in the supine position. Exclusion criteria included open or extra-articular endoscopic hip surgery. Post-related complications included pudendal nerve injury (sexual dysfunction, dyspareunia, perineal pain or numbness) or perineum/external genitalia soft-tissue injury.

RESULTS

Ninety-four studies (12,212 hips; 49% male, 51% female; 52% Level IV evidence) were analyzed. Prospective studies (3,032 hips) report a greater incidence of post-related complications compared with retrospective (8,116 hips) studies (7.1% vs 1.4%, P < .001). Three studies (1,064 hips) used a postless technique and all reported a 0% incidence of pudendal neurapraxia or perineal soft tissue injury. Most pudendal nerve complications were transient, resolving by 3 months, but permanent nerve injury was reported in 4 cases. Only 19%, 22%, 7%, and 4% of studies reported a total surgery time, traction time, traction force, and bed Trendelenburg angle for their study samples, respectively.

CONCLUSIONS

The incidence of post-related complications is 5 times greater in prospective (versus retrospective) hip arthroscopy literature. Postless distraction resulted in a 0% incidence of post-related injuries.

LEVEL OF EVIDENCE

IV, systematic review of Level I-IV evidence.

Surgeon-Specific Traction Time During Hip Arthroscopy for Primary Labral Repair Can Continue to Decrease After a Substantial Number of Surgeries

PURPOSE

The purpose of this study was to evaluate the total traction time and traction time as a function of anchors placed (TTAP) for primary labral repair in patients undergoing hip arthroscopy by a single surgeon.

METHODS

Patients were included if they received a primary labral repair with or without acetabuloplasty, chondroplasty, or ligamentum teres debridement as part of the treatment for femoroacetabular impingement (FAI). Patients were excluded if they had a previous ipsilateral hip surgery, prior hip conditions, Tönnis grade >1, open procedures, microfracture, ligamentum teres reconstruction, or labral reconstruction. TTAP was calculated by dividing total traction time by the number of anchors placed.

RESULTS

2,350 hips met the inclusion criteria. The mean age and BMI in this cohort were 34.22 years and 25.72 kg/m², respectively. A total traction time of 60 minutes was first achieved after 268 cases. Mean overall total traction time was 58.16 minutes (95% CI [57.35, 58.97]) and mean TTAP was 16.24 minutes (95% CI [15.93,16.55]) after 2,350 cases. Total traction time plateaued after 374 cases at 55.92 minutes, while TTAP plateaued after 487 cases at 14.93 minutes.

CONCLUSION

Surgeons who introduce hip arthroscopy into their practice can expect to see improvements in traction time during the first 500 surgeries performed, as total traction time plateaued after 374 cases and TTAP plateaued after 487 cases.

LEVEL OF EVIDENCE

IV: case series.

Sexual and urinary function post-surgical treatment of femoroacetabular impingement: experience from the FIRST trial and embedded cohort study

The goal of this study was to investigate the sexual and urinary function and any related complications in patients post-hip arthroscopy for the treatment of femoroacetabular impingement (FAI). Data from 214 patients enrolled in the FIRST trial and 110 patients enrolled in the trial’s embedded prospective cohort study (EPIC) were analyzed. EPIC patients either refused to participate in the trial or did not meet the FIRST eligibility criteria. Outcomes included the International Consultation on Continence Questionnaire (ICIQ) for males (ICIQ-MLUTS) and females (ICIQ-FLUTS) and the Female Sexual Function Index (FSFI) and International Index of Erectile Function (IIEF) administered before surgery and at 6 weeks and 12 months. Urinary and sexual function adverse events were recorded up to 24 months. Linear regression analyses were conducted to compare the osteochondroplasty and lavage groups in the FIRST trial and to evaluate age and traction time as prognostic factors among all patients. Longer traction time was associated with a small but statistically significant improvement in urinary voiding function in males at 6 weeks and 12 months (MD (95% CI) = 0.25 (0.12, 0.39), P &lt; 0.001 and 0.21 (0.07, 0.35), P = 0.004), respectively. Mean traction time was 43.7 (± 23.2) min for FIRST trial and 52.8 (± 15.2) min for EPIC cohort patients. Increasing age in male patients was associated with a decrease in urinary continence at 6 weeks (MD (95% CI) = 0.25 (−0.42, −0.09), P = 0.003). FIRST male patients who received osteochondroplasty improved significantly in sexual function at 12 months compared to males in the EPIC cohort (MD (95% CI) = 2.02 (0.31, 3.72), P = 0.020). There was an overall complication rate of 1.2% at 24 months [one urinary infection, two instances of erectile dysfunction (one transient and one ongoing at 24 months) and one reported transient numbness of tip of the penis]. Hip arthroscopy for the treatment of FAI has a low rate of sexual and urinary dysfunction and adverse events.

Hip Arthroscopy With and Without A Perineal Post: A Comparison of Early Postoperative Pain

PURPOSE

To compare postoperative pain and early recovery after hip arthroscopy with and without a perineal post for joint distraction.

METHODS

We retrospectively reviewed a consecutive series of patients who underwent hip arthroscopy before and after the adoption of a postless technique. Patients who underwent concurrent periacetabular or femoral osteotomy were excluded. Demographic information, procedure variables, and visual analog scale (VAS) pain scores were recorded. Analgesic medications given were converted to morphine milligram equivalents (MME) for comparison. Uni- and multivariate analyses were conducted to compare total MME, postoperative pain, and time to discharge between groups.

RESULTS

One hundred patients were in each group. The overall age (mean ± standard deviation) was 26.5 ± 9.9 years (Post [P]: 57 females; No Post [NP]: 68 females). Total operative time (P 100.4 ± 17.9 minutes vs NP 89.1 ± 25.5 minutes, P = .0004), traction time (P 45.8 ± 10.3 minutes vs NP 40.9 ± 11.1 minutes, P = .0017), and operating room time (P 148.8 ± 19.3 minutes vs NP 137.3 ± 25.8 minutes, P = .0005) were found to be shorter in the NP group. Total MME, and final VAS pain scores in the PACU were similar between both groups (MME, P = .1620; VAS, P = .2139). Time to discharge was significantly shorter in the NP group (P 207.2 ± 58.8 vs NP 167.5 ± 47.9, P < .0001). Patient age (≥25 years) (65.2 ± 18.1 vs 59.8 ± 15.7 [MME], P = .0269) and elevated body mass index (≥25) (65.1 ± 17.1 vs 59.3 ± 16.4 [MME], P = .0164) were factors associated with greater total MME consumption. Female sex was associated with higher postoperative VAS pain scores (FM 4.1 ± 1.6 vs M 3.4 ± 1.8 P = .0027).

CONCLUSIONS

Adoption of the postless technique did not result in prolonged operating room or operative time. Overall, both groups had similar postoperative pain, however, the time from surgery to hospital discharge was shorter in the postless group.

LEVEL OF EVIDENCE

III, retrospective comparison study.

History, indications, and advantages of orthopaedic operating room tables: a review

Although surgical procedures have been occurring as early at 6500 BC, the modern sense of the operating room (OR) did not exist until more recently. As aseptic techniques and surgical procedures began to evolve, so too did the OR table. The OR table began to transition from a static, wooden table to a dynamic table with the ability to position patients for a variety of procedures. With the advent of intraoperative imaging for orthopaedic procedures, OR tables have adapted and allow for imaging of bony anatomy by using radiolucent materials. These changes have led to the development of numerous OR tables, each with their own sets of advantages and disadvantages. There is currently no summary of the development, indications, benefits, and disadvantages of the various OR tables available to orthopaedic surgeons in the literature. The purpose of this review is to provide a comprehensive review of orthopaedic operating tables for both the junior orthopaedic resident and experienced attending surgeon.

The Pink Pad: A Method of Post-Free Distraction During Hip Arthroscopy

Distraction is essential during hip arthroscopy to allow for adequate working space during central and peripheral compartment procedures. Pudendal posts are frequently used with traction boots to achieve distraction, but use of these posts is believed to be associated with the iatrogenic pudendal area and perineal nerve injuries seen with hip arthroscopy. Current post-free distraction tables are costly and cumbersome. The pink pad positioning device allows for post-free distraction through the creation of friction between the patient, the pad, and the bed. This device can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty, as there is less restriction of the patient's range of motion without a post present. The purpose of this Technical Note is to describe a method of post-free distraction using the pink pad positioning device.

Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome

Pudendal nerve entrapment syndrome is widely unknown and often misdiagnosed or confused with other pelvic floor diseases. The aim is to develop a diagnostic and therapeutic algorithm based on a review of the existing literature. For its diagnosis, an anamnesis will be carried out in search of possible aetiologies, surgical history, and history of pain, assessing location and irradiation, intensity on the visual analogue scale, timing, triggering factors and rule out alarm signs. A physical examination will be performed, looking for trigger points or areas of fibrosis with transvaginal / transrectal palpation of the terminal branches of the nerve. With a doubtful diagnosis, an anaesthetic block of the pudendal nerve can be performed. Once the diagnosis is confirmed, the treatment will begin staggered with lifestyle changes, drug therapy and physiotherapy. In view of the failure of these measures, invasive therapies such as botulinum toxin injection, pulsed radiofrequency and decompression surgery or spinal cord stimulation will be used.

Limitations of Postless Hip Arthroscopy for a Patient with Coxa Profunda: A Case Report

CASE

A 27-year-old man with coxa profunda and a right acetabular labral tear presented for surgical re-evaluation after a postless arthroscopic labral repair was attempted at an outside institution and aborted because of inadequate distraction during portal placement. Arthroscopic labral repair with a perineal post was subsequently performed without complications.

CONCLUSION

Indications and limitations of postless hip distraction are seldom discussed in the literature. This report examines possible limitations of postless hip distraction for a patient with coxa profunda. Careful radiographic evaluation of hip anatomy may be essential for patients with deep hip sockets to determine the best-suited distraction technique.

Surgeon Experience in Hip Arthroscopy Affects Surgical Time, Complication Rate, and Reoperation Rate: A Systematic Review on the Learning Curve

PURPOSE

To systematically review the literature to (1) identify the reported learning curves associated with hip arthroscopy and (2) evaluate the effect of the stated learning curves on outcomes, such as complication rates, surgical and traction time, reoperation rates, and patient-reported outcome score (PRO) improvements.

METHODS

Two independent reviewers screened the PubMed-MEDLINE, Embase, and Cochrane Library electronic databases from inception to January 2020 according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The following search algorithm was used: "hip arthroscopy" paired with "learning curve," "competence," "experience," "performance," and "motor skills." Data regarding study characteristics, patient demographic characteristics, PROs, and learning-curve analyses were collected.

RESULTS

We identified 15 studies that reported the impact of the learning curve on surgical progress or clinical outcome measures. Measures of the surgical process included surgical and traction time, as well as fluoroscopy time, whereas clinical outcome measures encompassed PROs, complication rates, and reoperation rates. Three studies reported that the learning curve plateaued at 30 cases, but other studies suggested cutoff points ranging from 20 to 519. Operative time (75-119 minutes vs 45-99 minutes), traction time (55-127 minutes vs 54-112 minutes), complication rates (0.5%-43.3% vs 0.5%-18.0%), revision arthroscopy rates (3.3%-10% vs 1.0%-4.2%), and rates of conversion to total hip arthroplasty (12.2%-22.5% vs 1.5%-3.7%) decreased as surgeons gained more experience. Favorable PROs were observed throughout the surgeons' experience.

CONCLUSIONS

Progression along the learning curve of hip arthroscopy led to decreases in complication rates, surgical and traction time, and reoperation rates. PROs benefited from surgery throughout the learning curve. Currently, there exists a wide spread of cutoff numbers proposed to achieve proficiency, ranging from 20 to over 500.

LEVEL OF EVIDENCE

Level IV, systematic review of Level IV studies.

The Hip Arthroscopy Post-less Procedure Impingement (HAPPI) Technique: Achieving Distraction With Standard Hip Tables at Zero Additional Cost

Hip arthroscopy is becoming a more common treatment for femoroacetabular impingement, labral tears, and a variety of other hip pathologies. Unlike arthroscopy of the shoulder and knee, hip arthroscopy requires a significant amount of traction to gain access into the joint. Historically, traction has been achieved with the use of a perineal post. The use of a perineal post in hip arthroscopy can cause several avoidable complications such as neuropraxias (i.e., the pudendal nerve), vaginal or scrotal injuries, and perineal skin injuries. Several articles have been proposed using post-less techniques to obtain hip traction, but many of these techniques are expensive and require the purchase of new equipment. The purpose of this Technical Note is to describe a post-less technique for hip arthroscopy, the HAPPI technique (hip arthroscopy post-less procedure impingement), which is more affordable and does not require the addition of any special equipment. In addition, we will review some pearls and pitfalls, as well as advantages and disadvantages of the proposed technique.

Stepwise Safe Access in Hip Arthroscopy in the Supine Position: Tips and Pearls From A to Z

Hip arthroscopy is rapidly growing as a treatment with good outcomes for pathologic conditions such as femoroacetabular impingement syndrome and labral tears. At the same time, it is one of the most technically challenging and demanding procedures in orthopaedics with a technically demanding skill. The first challenge is to safely access the joint, which requires accurate anatomical knowledge, a strong sense of spatial orientation, and repeated practice. Iatrogenic chondrolabral injury has been reported as the most common complication in hip arthroscopy and most frequently occurs during hip joint access. As such, basic foundations cannot be overstated. These complications can be minimized with adequate patient positioning, reproducible hip joint access techniques, and proper portals placement. Nonetheless, these three points are perhaps the greatest hurdles that orthopaedic surgeons face when entering the hip arthroscopy field. In this review, we outlined a stepwise approach for a safe access to hip arthroscopy.

Reducing the "Irreducible" Total Hip Arthroplasty Dislocation with a Fracture Table: A Case Report

CASE

Reduction of dislocated total hip arthroplasty components is a challenging clinical scenario. Although component revision is recommended as a definitive treatment for those with recurrent instability, immediate reduction is required after an acute dislocation. We describe the case of a dislocated total hip arthroplasty and present a novel method for obtaining reduction after other closed techniques had failed.

CONCLUSIONS

Based on this case, utilization of a fracture table to generate adequate axial traction can aid orthopedic surgeons in obtaining reduction of a challenging dislocated hip prosthesis.

Traction force for peroperative hip dislocation in hip arthroscopy

OBJECTIVES

Traction force widens the joint space during hip arthroscopy. It is unclear how much the traction force varies and if it is related to the joint space widening. Main goal of our study was to measure the amount of force needed to widen the hip joint. Second goal was to study the relation between this force and the amount of joint space widening.

METHODS

Traction force was measured in 27 patients (of whom 24 female, mean age 41) during arthroscopy. Measurements were performed before the procedure, after vacuum seal release and after capsulotomy. Joint space widening was measured with fluoroscopy and was calibrated. Friedman and Wilcoxon tests were used to measure differences in traction. The Spearman's rho correlation coefficient was used to identify a correlation in traction force and joint space widening. Regression analyses were used to identify relations between age, body mass index (BMI), hip degeneration and traction force.

RESULTS

The median traction force before arthroscopy was 714 N, lowered to 520 N after vacuum seal release and to 473 N after capsulotomy (p < 0.001). Median joint space widening was 8.8 mm. Spearmans' rho correlation between traction force and joint space widening was ‒0.13.

DISCUSSION

Median traction force of 714 N resulted in 8.8 mm of joint space widening. This traction force was significantly lowered by 200 N after release of the vacuum seal of the hip and 250 N after additional capsulotomy without loss of joint space narrowing. No significant relation was identified for age, BMI or progression of the Kellgren-Lawrence classification for hip degeneration and traction force. Netherlands Trial Registry number 8610.

The impact of acetabular labral tears on sexual activity in women

A healthy sex-life is an important component of a good quality of life. However, sexual function may be inhibited in women with acetabular labral tears because of the labrum being caught between the femoral head neck junction and the acetabular rim during flexion and/or abduction of the hip. The aim of this article is to quantify the effect that acetabular labral tears may have on the sexual lives of women and to establish the extent to which they may be expected to resolve after arthroscopic intervention. The article also highlights the importance of including questions related to the impact on sexual activity as a routine part of our taking history for a young adult with hip pain, to gain a true appreciation of the impact the symptoms have on the day-to-day lives of our patients.

Knee Flexion Angle During Graft Fixation for Medial Patellofemoral Ligament Reconstruction: A Systematic Review of Outcomes and Complications

PURPOSE

To determine the effect of knee flexion angle during graft fixation on outcomes and complications following medial patellofemoral ligament (MPFL) reconstruction.

METHODS

Three databases (PubMed, EMBASE, and MEDLINE) were searched from database inception to January 2018. After screening based on inclusion and exclusion criteria, patient demographics, fixation technique, graft selection, outcomes, and complications were extracted from the included studies. The studies were grouped based on flexion angle used during graft fixation: low (0°-30°) and high (45°-90°) flexion angle group. Methodological Index for Non-Randomized Studies criteria were used to assess the quality of each included study. Descriptive statistics are presented.

RESULTS

Seventeen studies (of 3,399) were included and were either cohort (n = 1) or case series (n = 17) study designs. A total of 556 patients with a mean age of 23.6 years (range, 10-60 years) underwent MPFL reconstructions, with 458 patients in the 0° to 30° fixation group and 98 in the 45° to 90° fixation group. The mean Kujala score improved from 45 to 72.9 (365 patients) preoperatively to 83 to 94.5 (460 patients) postoperatively for the 0° to 30° fixation group and from 53.3 to 72 preoperatively to 92.2 to 95.2 postoperatively for the 45° to 90° fixation group (98 patients).

CONCLUSIONS

The knee flexion angle during MPFL graft fixation ranges from 20° to 90°. Graft fixation at low and high knee flexion angles during MPFL reconstruction showed excellent patient-reported outcomes and low patellar redislocation rates overall, with no clear differences between the 2 groups based on the currently available data.

LEVEL OF EVIDENCE

Level IV, systematic review of Level III-IV studies.

Femoroacetabular impingement: prospective study of rate and factors related for nerve injury after hip arthroscopy

Prospective, longitudinal, descriptive study was conducted from January 2016 to January 2018 to detect nerve dysfunction after hip arthroscopy. A total of 110 patients were included. Twenty-four hours after surgery, 62.7% reported symptoms of abnormal sensation at least in one area. The most common was the perineal area. Three weeks after hip arthroscopy, 42.6% still experienced abnormal sensation. Six months after hip arthroscopy, only one patient remained with symptoms. Nerve dysfunction after HA was more common than has been reported in the literature within large populations. Traction time was a significant factor for the development of perineal nerve dysfunction.

Achieving Post-Free Distraction in Hip Arthroscopy With a Pink Pad Patient Positioning Device Using Standard Hip Distraction Tables

Iatrogenic pudendal nerve and groin complications have been reported to occur at rates up to 4.3%. While many of these complications are transient, the hip preservation community is in search of a safe postless distraction technique. Currently available postless distraction tables are expensive, require the surgeon to adopt a different technique, and have a high disposable fee. We present our technique for postless distraction using a standard table and a pink pad positioning device. Using our technique, we have demonstrated safe and cost-effective post-free distraction.

Elbow flexion angle during graft fixation for ulnar collateral ligament reconstruction: a systematic review of outcomes and complications

BACKGROUND

The ulnar collateral ligament (UCL) of the elbow is commonly injured in overhead athletes, especially baseball pitchers. UCL reconstruction has shown good outcomes regarding return to play, but revision rates are on the rise. This review was conducted to determine the effect of elbow flexion angle during graft fixation on outcomes and complications after UCL reconstruction.

METHODS

MEDLINE, Embase, and PubMed were searched from database inception to November 16, 2017. Patient demographics, surgical technique, graft selection, outcomes, and complications were extracted from the included studies. The quality of each study was assessed in duplicate with the Methodological Index for Non-Randomized Studies criteria. Descriptive statistics are presented.

RESULTS

Six studies, with a total of 1168 patients, were included, and all were case series. Excellent Conway scores were present in 83.8% of patients for the 0° to 30° group and in 91.1% of patients for the 45° to 70° group, with no significant differences in return to play between the groups. The rate of revision UCL reconstruction was significantly higher with graft fixation at 0° to 30° (1.4%) compared with fixation at 45° to 70° (0%; P < .01).

CONCLUSIONS

Elbow flexion angle during graft fixation may not influence return to the same or higher level of competition but appears to influence the need for a revision after UCL reconstruction. However, the available current evidence possesses a high degree of fragility, and further studies are needed with objective measurements to determine the optimal elbow flexion angle for graft fixation.