Hello, this is Dr. Al Stubbs from Wake Forest University presenting the approach to the failed hip arthroscopy. My disclosures can be found on the AOS website. With a failed hip arthroscopy procedure, the real question is now what? There's oftentimes issues with incorrect diagnosis, incorrect procedure, insufficient procedure, incorrect rehabilitation, maybe bad biology of the patient, or a new problem or pathology that is atrogenic in nature. And sometimes it was never an orthopedic problem to begin with. There are many diagnoses that have emerged over the last 20 years, including instability, chondrolateral dysfunction, tears of muscles and tendons, impingement, as well as atypical findings. In the 1990s, hip pain was often found as either strains, sprains, or arthritis, and most studies were read as normal. As we've moved forward into the 2000s, most studies are read as abnormal, and it makes it more incumbent upon the surgeon to make sure they have the correct diagnosis. Probably what's most important is understanding the concept of the hip at risk. We see this in contact athletes, extreme physiology athletes, as well as special circumstances. And really in sports medicine, we're on the front line of this epidemic. The modes of FAI surgery failure oftentimes come down to an unstable chondrolateral interface or under resection of impinging bone. But we have seen other diagnoses that become a problem as well, including progressive hip arthritis, adhesions, unrecognized dysplasia, as well as problems with rehabilitation. The critical questions are, is the pain the same as it was before surgery? Are you better or worse? What kind of response have you had to diagnostic injections? And what are the expectations of the patient and the surgeon? One of the most difficult decisions is the timing of outcomes, when to call a procedure of failure. The history of complaints does seem to make a difference. Is it different or the same as pre-op? Are there mechanical symptoms? Is there night pain? Is there pain with weight bearing? The primary decision drivers for post-op imaging really have to do with what are the history of the complaints, your physical exam findings, the quality of preoperative imaging, as well as the scope of preoperative imaging. There are at least 10 theories as to why the chondrolateral junction fails, and understanding these is paramount to being able to approach the failed hip. Clinical evaluation relies on the basics, a good history, physical exam, and imaging. You suspect an intra-articular diagnosis when you start to see asymmetric findings. Intra-articular findings are often where you have symmetric joint findings and negative provocative tests, but you have selective muscle function and weakness. On the physical exam, we have a very routine exam that involves inspection, palpation, range of motion, ligament testing, functional testing, as well as gait assessment. Again, the keys to the physical exam are looking for asymmetric range of motion, positive impingement testing, and other findings such as this modified Faber's test. Imaging tools really rely on the basics, good plain films, MRI, as well as dynamic fluoroscopy. We occasionally use ultrasound and CT for dynamic software analysis and an occasional bone scan. I typically avoid contrast because it can interfere with assessing where there may be soft tissue pathology, as well as creating additional trauma for the patient. It may have a role in assessing capsular insufficiency. Let's look at some intra-articular failures. Here's an example of capsular labral adhesions. You can see the pre- and post-op imaging looks fairly consistent and good, but an intra-operative finding shows these adhesions. If someone's had a debridement, here's a residual labral tear. Here's an example of labral insufficiency after over-resection and debridement. Here's an example of a capsular defect brought out by intra-articular contrast. How about subchondral edema? This is where MRI can be very helpful in the post-operative setting. We oftentimes will see contracous cystic change, which is really insidious posterior inferior osteoarthritis. MRI is good for that as well. We do see chondrolysis related to a variety of findings, including excessive RF within the joint. You can see this iliopsoas impingement type cyst. Here's an example of good anchor placement, as well as good anchor placement. Here's an example of anchor erosion, so this is not okay when you have an anchor that goes transchondral. Here's an example of cystic change that's occurred post-operatively related to abnormal resorption of anchors. Here's an example of inadequate resection of mixed FAI. An example of an inadequate femoroplasty. CT sometimes can be beneficial in these cases. Here's an example of edema showing residual impingement on an MRI. Here's an example of post-operative calcification across the acetabulum with residual pincer lesion. Here's an example of an over-resection on plain film, MRI, MRI again, and MRI again. Here's an example of an over-resection of the contralateral hip, showing the over-medialization as evidenced by resecting beyond the equator of the femoral head. MRI radial reformatting can be helpful sometimes with this. How about extra-articular failures? This is showing core muscle injury on an MRI post-operatively. This is demonstrating a right-angular hernia. Here's some residual subspinous impingement with subchondral cystic change, as well as changes across the femoral neck with associated cystic change. Here's an example of unrecognized acetabular dysplasia with subsequent advancement of arthritis. Here's an example of a patient who had hip surgery, came back, MRI showed acetabular lymphoma. How about excessive femoral amniotorsion? You want to be very careful with releasing psoas tendons in these cases. Here's an example of an osteochondroma that was not recognized during the first case, but was identified intraoperatively on a fluoroscopic evaluation. Inflammatory arthropathy can exist in approximately 5% of our patients. You can see these changes on post-operative MRI. Bone scanning can be helpful for picking up hotspots, such as osteoid osteoma, as well as spondylolisis. So, in summary, history and physical exams still matter. Utilize advanced imaging and analysis, patient risk assessment to avoid failed FAI surgery. Thank you.

failed hip arthroscopy procedures

diagnoses

post-operative complications

thorough clinical evaluation

patient risk assessments