Complications in Hip Arthroscopy

A Portable Hip Arthroscopy Simulator Demonstrates Good Face and Content Validity with Incomplete Construct Validity

Purpose

We evaluate the face, content, and construct validity of a portable hip arthroscopy module in a regional orthopaedic unit.

Methods

Participants were recruited from a regional orthopaedic centre, and categorized into novice (0 arthroscopies), intermediate (1-29 arthroscopies), and expert (>50 arthroscopies) groups based on reported experience in arthroscopy. Face and content validity was evaluated by feedback from users immediately following completion of modules. Objective measurements, including time taken and subjective measurements consisting of simulation software metrics including, cam lesion locations attempts, scope strikes on bone, healthy bone burred, and cam lesion burred. Scores achieved by experts were recorded, and the median score was set at the level at which proficiency was demonstrated. Participant feedback on perceived educational use was collected following completion.

Results

In total, 20 participant results were included for analysis. Good face and content validity was expressed by participants with previous arthroscopic experience. Number of scope strikes within the simulator-derived metrics accurately discerned between levels of experience. Novices had a mean of 5 strikes per attempt (SD ± 5 ) ,  intermediates a mean of 5.8 strikes (SD ± 4.1). There was a significant difference between expert and novice groups (P = .01), and expert and intermediate groups (P = .002). No significant difference between overall performance scores achieved by participants in expert, intermediate, and novice groups (62% ± 19 vs 55% ± 22 vs 50% ± 23 , P = .15). This demonstrates incomplete construct validity of the simulator software-derived metrics.

Conclusions

This hip arthroscopy simulator demonstrated acceptable face and content validity, with incomplete construct validity of simulator software metrics. Participants reported high levels of satisfaction with the module, highlighting that the addition of haptic feedback would be beneficial to improve procedural steps. Incorporation of tactile feedback to the modulator components would likely enable the software to accurately delineate between levels of experience.

Clinical Relevance

This study demonstrates good face and content validity. The addition of haptic feedback in a hip arthroscopy simulator may improve learning.

Outcomes following surgical management of femoroacetabular impingement: a systematic review and meta-analysis of different surgical techniques

Outcomes following different types of surgical intervention for femoroacetabular impingement (FAI) are well reported individually but comparative data are deficient. The purpose of this study was to conduct a systematic review (SR) and meta-analysis to analyze the outcomes following surgical management of FAI by hip arthroscopy (HA), anterior mini open approach (AMO), and surgical hip dislocation (SHD). This SR was registered with PROSPERO. An electronic database search of PubMed, Medline, and EMBASE for English and German language articles over the last 20 years was carried out according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We specifically analyzed and compared changes in patient-reported outcome measures (PROMs), α-angle, rate of complications, rate of revision, and conversion to total hip arthroplasty (THA). A total of 48 articles were included for final analysis with a total of 4,384 hips in 4,094 patients. All subgroups showed a significant correction in mean α angle postoperatively with a mean change of 28.8° (95% confidence interval (CI) 21 to 36.5; p < 0.01) after AMO, 21.1° (95% CI 15.1 to 27; p < 0.01) after SHD, and 20.5° (95% CI 16.1 to 24.8; p < 0.01) after HA. The AMO group showed a significantly higher increase in PROMs (3.7; 95% CI 3.2 to 4.2; p < 0.01) versus arthroscopy (2.5; 95% CI 2.3 to 2.8; p < 0.01) and SHD (2.4; 95% CI 1.5 to 3.3; p < 0.01). However, the rate of complications following AMO was significantly higher than HA and SHD. All three surgical approaches offered significant improvements in PROMs and radiological correction of cam deformities. All three groups showed similar rates of revision procedures but SHD had the highest rate of conversion to a THA. Revision rates were similar for all three revision procedures.

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.

Portal enlargement in hip arthroscopy preserving the iliofemoral ligament: a novel access technique protecting soft tissue restraints

Capsulotomy in different modalities has been used to provide adequate exposure to access both the central and peripheral compartment in hip arthroscopy. Even though the hip joint has inherent bony stability, soft tissue restraints may be important in patients with ligaments hyperlaxity or in some cases with diminished bony stability. Biomechanical studies and clinical outcomes have shown the relevant role of the capsule in hip stability, mainly the role of the iliofemoral ligament. Although is not very common, iatrogenic post-arthroscopy subluxation and dislocation have been reported and many surgeons are concerned about the role aggressive capsulotomy or capsulectomy in this situation, thus capsule repair has become very popular. We present a novel technique to access the hip without cutting the iliofemoral ligament. With this technique we can obtain adequate arthroscopic access to the hip joint in order to treat adequately the central compartment pathologies reducing the risk of iatrogenic post-operative hip instability.

Intra-abdominal Fluid Extravasation: Is Endoscopic Deep Gluteal Space Exploration a Risk Factor?

Background

The extravasation of fluid into the intra-abdominal space is recognized as a possible complication of hip arthroscopic surgery/endoscopy. The exposure of anatomic areas to elevated pump pressures and high volumes of irrigation fluid increases the risk of fluid leakage into anatomic spaces around the hip joint, especially to the abdomen and pelvis.

Purpose

To estimate the incidence and risk factors related to intra-abdominal fluid extravasation (IAFE) after hip endoscopy or arthroscopic surgery.

Study Design

Cohort study; Level of evidence, 2.

Methods

A prospective study was carried out between June 2017 and June 2018. A total of 106 hip procedures (endoscopy or arthroscopic surgery) performed for extra- or intra-articular abnormalities were included. Before and after surgery, in the operating room, ultrasound was performed by a trained anesthesiologist to detect IAFE. The hepatorenal (Morison pouch), splenorenal, retroaortic, suprapubic (longitudinal and transverse), and pleural spaces were examined. Patients were monitored for 3 hours after surgery to assess for abdominal pain. The data collected included maximum pump pressure, duration and volume of irrigation fluid (Ringer lactate), total surgical time, and traction time.

Results

The incidence of IAFE was 31.1% (33/106; 95% CI, 23.1%-40.5%). The frequency of IAFE was 52.9% (9/17) in cases with isolated extra-articular abnormalities and 15.9% (7/44) in cases with isolated femoroacetabular impingement; in cases with both extra- and intra-articular abnormalities, the frequency was 37.8% (17/45). An intervention in the subgluteal space was identified as a risk factor for IAFE (odds ratio, 3.62 [95% CI, 1.47-8.85]). There was no statistically significant difference between groups (with vs without IAFE) regarding total surgical time, maximum pump pressure, or fluid volume. Postoperative abdominal pain was found in 36.4% (n = 12) of cases with IAFE compared with 2.7% (n = 2) of cases without extravasation (P < .001). No patient with IAFE developed abdominal compartment syndrome.

Conclusion

IAFE was a frequent finding after hip arthroscopic surgery/endoscopy in patients with extra-articular abnormalities. Exploration of the subgluteal space may increase the risk of IAFE. Pain and abdominal distension during the immediate postoperative period were early warning signs for IAFE. These results reinforce the need for careful intraoperative and postoperative monitoring by the surgeon and anesthesiologist to identify and avoid complications related to IAFE.

Does Arthroscopic Repair of Femoroacetabular Impingement Pathology Affect Clinical Outcomes after Ipsilateral Total Hip Arthroplasty?

PURPOSE

Arthroscopy for repair of femoroacetabular impingement (FAI) and related conditions is technically challenging, but remains the preferred approach for management of these hip pathologies. The incidence of this procedure has increased steadily for the past few years, but little is known about its potential long-term effects on future interventions. The purpose of this study was to evaluate whether prior arthroscopic correction of FAI pathology impacts postoperative complication rates in patients receiving subsequent ipsilateral total hip arthroplasty (THA) on a national scale.

MATERIALS AND METHODS

A commercially available national database - PearlDiver Patients Records Database - identified primary THA patients from 2005 to 2014. Patients who had prior arthroscopic FAI repair (post arthroscopy group) were separated from those who did not (native hip group). Prior FAI repair was examined as a risk factor for complications following THA and a multivariable logistic regression analysis was applied to identify risk factors for complications following THA.

RESULTS

A total of 11,061 patients met all inclusion and exclusion criteria; 10,951 in the native hip group and 110 in the post arthroscopy group. Prior FAI repair was not significantly associated with higher rates of 90-day readmission (P=0.585), aseptic dislocation/revision within 3 years (P=0.409), surgical site infection within 3 years (P=0.796), or hip stiffness within 3 years (P=0.977) after THA.

CONCLUSION

Arthroscopic FAI repair is not an independent risk factor for complications following subsequent ipsilateral THA (level of evidence: III).

The learning curves of a validated virtual reality hip arthroscopy simulator

INTRODUCTION

Decreases in trainees' working hours, coupled with evidence of worse outcomes when hip arthroscopies are performed by inexperienced surgeons, mandate an additional means of training. Though virtual reality simulation has been adopted by other surgical specialities, its slow uptake in arthroscopic training is due to a lack of evidence as to its benefits. These benefits can be demonstrated through learning curves associated with simulator training-with practice reflecting increases in validated performance metrics.

METHODS

Twenty-five medical students with no previous experience of hip arthroscopy completed seven weekly simulated arthroscopies of a healthy virtual hip joint using a 70° arthroscope in the supine position. Twelve targets were visualised within the central compartment, six via the anterior portal, three via the anterolateral portal and three via the posterolateral portal. Task duration, number of collisions (bone and soft-tissue), and distance travelled by arthroscope were measured by the simulator for every session of each student.

RESULTS

Learning curves were demonstrated by the students, with improvements in time taken, number of collisions (bone and soft-tissue), collision length and efficiency of movement (all p < 0.01). Improvements in time taken, efficiency of movement and number of collisions with soft-tissue were first seen in session 3 and improvements in all other parameters were seen in session 4. No differences were found after session 5 for time taken and length of soft-tissue collision. No differences in number of collisions (bone and soft-tissue), length of collisions with bone, and efficiency of movement were found after session 6.

CONCLUSIONS

The results of this study demonstrate learning curves for a hip arthroscopy simulator, with significant improvements seen after three sessions. All performance metrics were found to improved, demonstrating sufficient visuo-haptic consistency within the virtual environment, enabling individuals to develop basic arthroscopic skills.

Metabolic and Hemodynamic Results and Early Complications in Simultaneous Bilateral versus Unilateral Hip Arthroscopy

Background

To compare the hemodynamic parameters—electrolyte concentration, D-dimer level, creatine phosphokinase level—and the incidence of early complications of simultaneous bilateral versus unilateral hip arthroscopy.

Methods

A prospective study was conducted on patients (> 18 years of age) undergoing unilateral or bilateral hip arthroscopy under the same anesthetic between 2013 and 2015. Patients were followed up for 30 days after surgery. In all cases, data were collected before, during, and after the surgical procedure.

Results

One hundred cases of hip arthroscopy (51 unilateral and 49 bilateral) were included in this study. There was a greater variation in systolic blood pressure and heart rate in the unilateral group. The sodium levels were higher in the bilateral group with an adjusted mean difference of 5.31 mmol/L (p < 0.001). During the first 24 hours after the procedure, the proportion of patients with an altered D-dimer of > 500 ng/mL was 85.7% in the bilateral group and 56.9% in the unilateral group. There was no significant difference in the incidence of complications between the groups (bilateral, 8.2%; unilateral, 9.8%; crude odds ratio, 0.83; 95% confidence interval, 0.24 to 2.92; p = 0.526).

Conclusions

The variations of hemodynamic parameters in patients undergoing hip arthroscopy remained within normal ranges. The findings of this study suggest that bilateral hip arthroscopy be selected according to the patient's condition, considering that the risk of complications and metabolic alterations in bilateral hip arthroplasty are similar to those in unilateral arthroscopy.

Preserving the chondrolabral junction reduces the rate of capsular adhesions

The operative treatment of pincer-type femoroacetabular impingement (FAI) has become an increasingly more common procedure. Classically, the labrum is incised at the chondrolabral junction (CLJ), or a concurrent tear is extended to allow access to the acetabular rim facilitating acetabuloplasty. The labrum is subsequently repaired using suture anchors. More recently, acetabuloplasty has been performed without incising the labrum and negating the need to use suture anchors. The aim of this study is to determine whether preserving the CLJ reduces the incidence of revision hip arthroscopy for the treatment of capsulolabral adhesions. This retrospective study compared two cohorts of patients undergoing hip arthroscopy for pincer-type FAI from August 2002 to April 2015. The groups analysed were patients undergoing acetabuloplasty with labral repair (LR) and those with no labral repair (NLR). The revision rates and causes for revision were compared using the χ² analysis. There were 1010 cases in total. Acetabuloplasty with LR was performed in 546 hips (519 patients), while acetabuloplasty with NLR was performed in 464 hips (431 patients). In the LR group, there were 54 (9.9%) revisions, 25 (46%) of which were due to capsulolabral adhesions. The NLR group had 36 (7.8%) revisions with six (17%) due to capsulolabral adhesions. Preserving the CLJ, thereby avoiding the need for drilling and the insertion of suture anchors, when performing an acetabuloplasty for pincer-type FAI, significantly reduces the rate of symptomatic adhesions requiring revision arthroscopy.

A systematic review-meta-analysis of venous thromboembolic events following primary hip arthroscopy for FAI: clinical and epidemiologic considerations

The purpose of this study was to report the proportion of venous thromboembolic events (VTE) in patients undergoing primary hip arthroscopy for femoroacetabular impingement (FAI) and present a critical overview of the literature to aid in better result interpretation. MedLine, Scopus and Web of Science databases were searched from January 2000 to March 2017. Four thousand-five-hundred and seventy-seven hip cases were included in the meta-analysis of 38 studies. The mean age of patients was 36 ± 1.8 years and the mean follow-up time was 20.6 months. The meta-analysed rate of deep vein thrombosis (DVT) in patients undergoing primary hip arthroscopy for FAI syndrome was 1.18%; 95%CI [0.8–1.74%]; The meta-analysed rate of pulmonary embolism (PE) in patients undergoing primary hip arthroscopy for FAI syndrome was 0.59%; 95%CI [0.38–0.92%]. Quality assessment was performed using the Methodological Index for Non-Randomized Studies (MINORS) criteria the Quality in Prognostic Studies (QUIPS) tool. Sensitivity analysis was conducted to assess for publication bias and its influence on the results. The corrected for publication bias proportion of DVT was 2.02%; 95%CI [1.36–2.99%]. The DVT rate was double following the correction of bias while additional types of bias were detected. Attention must be paid when considering the outcomes of observational studies to make clinical decisions. Insufficient evidence exists to support whether anti-VTE chemoprophylaxis should be administered to patients undergoing primary hip arthroscopy for FAI. Due to the life-threatening character of this complication, the results should serve as starting point to design clinical trials and establish guidelines. Until then, the application of preventive measures against VTE should be decided on a case-by-case basis.

Clinical outcomes following arthroscopic treatment of femoro-acetabular impingement using a minimal traction approach and an initial capsulotomy. Minimum two year follow-up

PURPOSE

Although the arthroscopic management of femoroacetabular impingement (FAI) is increasing, severe complications have been reported due to traction. We developed an arthroscopic technique based on an initial capsulotomy and a minimal traction approach. The main purpose of this study was to analyze the clinical outcomes of FAI treatment using this technique after at least two years of follow-up.

METHODS

Forty-seven consecutive patients underwent surgery for FAI. There were two initial portals: a proximal anterolateral portal and a distal anterior instrumental portal. An anterior working space was created and a T-shaped incision was made in the anterior capsule to relieve joint distraction. Short traction (less than 20 mn) made it possible to approach the central compartment. Acetabuloplasty was performed in the presence of pincer impingement. Traction was then released. A head-neck femoral osteochondroplasty was performed in case of bump impingement. All patients underwent a mean 3.3 ± one years of follow-up based on two self-administered questionnaires: the Harris hip score and the QOL Oxford score. None of the patients were lost to follow-up.

RESULTS

There were three complications: two ossifications and one case of injury to the femoral cutaneous nerve with good clinical outcomes at the final follow-up. Five patients (10%) underwent surgical revision after a mean 1.4 years of follow-up: three total hip arthroplasties, one peri-acetabular osteotomy, and one repeat arthroscopic hip debridement. The Harris score increased significantly from 60 ± 10 to 86 ± 15 (p < 0.0001) and the Oxford score improved from 34 ± 15 to 50 ± 11. Only 25% of patients had a "forgotten hip" at the final follow-up.

CONCLUSION

Our clinical results were comparable to previously reported outcomes with other surgical techniques for the management of FAI. However, it should also be noted that despite these good clinical outcomes, the percentage of patients with a "forgotten hip" is low, and patients should be informed of this.

Ganglion Cyst as a Rare Complication of Hip Arthroscopy Resolved With THA: A Case Report

BACKGROUND

A rare complication of hip arthroscopy is the development of a ganglion cyst. These cysts can affect structures surrounding the hip joint. In some cases, the femoral artery may be involved, leading to claudication or a pulsatile mass that can resemble an aneurysm.

CASE DESCRIPTION

We present the case of a 62 year-old male who complains of 3 months of right hip pain. Workup reveals a degenerative labrum with cam impingement. After a discussion of various treatment options, the patient elected for arthroscopy to correct the impingement. An anterior capsulotomy was created to establish access to the joint. Cam decompression was indicated to address the impingement. The patient developed a recurring ganglion cyst following the procedure that was not permanently prevented with cyst aspiration. Total hip arthroplasty with ganglion cyst decompression resolved the ganglion cyst and resolved the hip pain.

CONCLUSIONS

This is the first case report that describes the development of a ganglion cyst following hip arthroscopy. Arthroplasty and ganglion cyst decompression in the presence of degenerative joint disease presents a viable treatment option for these cysts. Additionally, this case suggests interportal capsulotomy closure may prevent ganglion cyst development and should be considered when performing hip arthroscopy.