So again, my name is Dr. Winston Gwathmey from the University of Virginia. It's interesting, Javon has always asked me to do this complications type talk. I'm not sure if he knows I have a lot of complications or I get in a lot of trouble, but I do like giving this talk. So hopefully we can have some fun with it. So here are my disclosures. And so I always like to think about Dr. Thomas Byrd is kind of how I learned all my hip arthroscopy. And he had a lot of great quotes. If you ever get a chance to work with him, I would do it. But one of my favorites is you don't have to see every complication for yourself. You can read about a few of them. And so hopefully this talk will help you with that. My second favorite quote he likes to tell me is experience is that thing that tells me I've made this mistake before. So what you'll see around you in this, during this course is a lot of excellent faculty. People have been doing hip arthroscopy for years and years and years, and we've all made mistakes. And the goal of this talk is going to help you live through my mistakes and maybe avoid a few of them. But definitely the complications expert amongst our faculty, Dr. Joshua Harris. He has the most literature on complications. I'm not sure that makes him the expert or not, but what he'll tell you when you look at the actual systematic reviews is there actually is a reasonable complication rate during hip arthroscopy. And what you'll probably see and be aware of is neuropraxia. So some type of either transient or permanent nerve injury, most often the LFCN. Cartilage damage, iatrogenically. Again, I talked about that during my access part. You want to be very careful that you don't damage the cartilage of the labrum when you're doing hip arthroscopy. During posted hip arthroscopy, you'll see a lot of post complications. Another complication sort of inherent to surgery infection, heterotopic ossification you'll see, but also some other major complications you don't want to see. So here's another good paper Dr. Chris Larsen put together looking at over 1,600 hip arthroscopies and four institutions. And you can see the complication rates is not zero. And again, the most common one you'll see is the LFCN disturbance. So here's what you're going to see. You will see at some point during your practice, these neuropraxias, you'll see labral damage, cartilage damage, iatrogenically. You'll see traction, compression injuries from traction. A lot of times you'll see incomplete FAI correction, which I think to me is probably the one that's most avoidable. DVT, wound problems, those types of things. Things you definitely do not want to see, hip dislocation, femoral neck fractures, AVN, compartment syndrome, and all these different things you definitely don't want to see in your practice. And so again, we'll try to avoid that. So when you're talking about hip arthroscopy, it's like the tiger in the grass, you know, it's just waiting to get you, I feel like sometimes. So when you post your first hip, you have to realize these are not hip, they're not, excuse me, the hip scopes are not knee or shoulder scopes. There's a chance that the first time you do a hip arthroscopy in whatever center you end up going to, your circulator, your scrub, your crew might not have ever seen one before, okay? So you want to be involved in the entire process from the bed set up, to the room set up, to making sure you have the right instruments, the patient positioning. And make sure, and again, I harp this on my personal, on my fellows at UVA, is that when you're doing hip scopes, you want to make sure that every step you do is as perfect as you can possibly make it, okay? If you accept sort of a mediocre execution on one of your steps, the next one is going to get worse and worse, and it's a cycle that will be hard to break as you go forward. Do not leave your operating room until you're happy with what you've done. You know, what you'll see is that, especially with FAI correction, you know, the best chance to get the perfect surgery is the first time you do it, and the last thing you want to do is leave the operating room with inadequate correction or a bad laboring repair that you could have fixed while you were in there. So I like this little picture of good intentions and bad results. We'll talk about mainly intraoperative and post-operative complications today we're going to try to avoid, okay? And again, I think the most important place to avoid trouble is preoperatively with indications, but that's a talk, that's a different talk altogether. So let's talk intraoperative. When you post your first hip, you know, this is like, I like these little minion guys that reminds me of sometimes the OR crew you end up working with. Imagine you're doing it in your garage with the overnight OBGYN crew. Again, nobody knows how to do hip arthroscopy in your hospital. Just assume that as you go in. It's not knee, it's not shoulder arthroscopy. Just the camera alone, you know, you've got a bridge, you have a 70 degree scope, you've got a cannula set up. The scope is longer than the average setup, you know? So if you have a normal shoulder or knee length scope, it won't fit into your apparatus, okay? You've got longer instruments. Make sure your equipment's compatible. So every single set's a little bit different. The Arthrex set, the Smith and Nephew set, the Stryker set, whatever set you might have, is not going to be compatible with the scope necessarily. So make sure your cannula, your bridge, and your scope is all compatible with each other. Well, this is an example of a case in which in the top picture, you've got a scope that fits into the assembly, but the bottom, you've got the wrong cannula with the wrong bridge. And so it doesn't fit in properly. And you can't scope in that scenario. And you think it's not going to happen, but it will happen to you at one point where you actually try to put yourself together. It's not compatible. So you want to check this preoperatively to make sure you don't get yourself in trouble. Make sure you're using the right scope. You get this picture, you're like, man, I swear, during my fellowship, I was working with Dr. Harris, I was working with Dr. Westerman, things looked much different. My scope doesn't look the same because maybe you're using a 30 degree scope, you see? So make sure you get the right scope. Make sure you verify you have the right scope when you go into that joint so you get that view that you're used to seeing. Again, the 30 degree and the 70 degree are very, very different as far as how you can see inside the joint. The reason why I use a 70 inside the hip is because there are a lot of funny angles in there. In order to get around the head, you have to have a 70 degree scope to be able to see that into your triangle and be able to do work inside the central compartment. Know your table. Every table is a little bit different. It's got different cranks, it's got different triggers, it's got different knobs to be able to apply that leg. And what always ends up happening is you're doing your scope and the moment you're about to move the leg, your circulator is left for lunch and suddenly you've got some traveler in there who's never even used that table. So you want to make sure your team knows how to run that table before the patient is draped. Sometimes it's as simple as just going through the actual table with the team before the patient's even in the room. Say this knob controls fine traction, this knob controls gross traction, this knob here is how you abduct and adduct. So again, once the patient's draped, it can be much more challenging to use those different knobs and levers and definitely have a plan. Plan your setup. So it's another one of those things you want to do a dry run before you even have your patient in the room. Are you going to take your fluoro from across the opposite side or between the legs? How is it going to fit in there? Where are you going to stand? Where is your assistant going to stand? Where is the scrub nurse? So I think having these kind of pictures in your mind are very helpful as far as knowing how you're going to set your room up. Because some rooms are bigger than others. Some rooms have fluoroscopy that can only come from a certain angle. So just be aware. In my room, for instance, one of my ORs is so small, I have to actually angle the entire body at a 20 degree angle off of the center of the room just so I can get fluoroscopy between the legs. Again, here's the setup you can have. So you can have fluoro from the opposite side, meaning coming across the table or from in between the legs. And so also know how you're going to be able to, if you need to manipulate that C-arm, if you tilt the back or something like that, can you do that with the setup that you have? Remember that traction has been used as a form of torture. It's inherently dangerous, okay? So you have to make sure everything you're doing is padded and you'll do a perfect hip arthroscopy and somebody will wake up on a nerve palsy because your team or you didn't properly have the elbow bent and padded. Make sure the feet are padded. You're going to have these people in boots for two hours, two and a half hours. Make sure the feet are properly padded to avoid any injury. Because a lot of times the actual injury that occurs isn't within the hip or the perineum, it's in the foot or within the elbow. Traction time is a lot like tourniquet time. You want to make sure you monitor it closely and work efficiently while you're on traction. So you'll have, the longer you're on traction, the more things can happen that are bad. And also you want to take any measures you can to decrease the force, whether it be trendelenburg positioning. Again, I'll probably put my, most of my hips about two or three degrees of trendelenburg just to kind of decrease the amount of pressure that they're seeing inside there. And you can also vent the capsule. I vent every capsule. I used to just vent a few or I used to think, oh, maybe I'll vent this capsule if I need to. But it's gotten to a point where I find that just venting the capsule empirically avoids a lot of just that, even the actual pressure inside the joint when you're venting the capsule releases that vacuum seal. And I see less ecchymosis within the labrum. I see just a hip that looks a little bit happier once I vent the capsule. The perineal post. Okay. Imagine having this thing shoved into your crotch for over an hour. So I've gone postless because of just the complications you can see with that. But back when I was using a post, I think that what you need to do is use an oversized perineal post. This is a proprietary post. It actually has a double foam in it that actually helps offload the forces of the perineum. So I think you need to use a larger post than standard, especially early in your hip arthroscopy practice, because we're using a standard post like you might use in a fracture table and you're putting them in the tract for two hours, you might find yourself with perineal or penile nerve complications. There's a problem with the post. And I apologize for this a little bit crude, but this is, I got an email from my patients back when I was using a post and the title is literally balls numbness and the balls and shaft are definitely numb. How long can you say this can last? You don't want these emails. I promise you that because it's not only awkward to answer, but also you could put yourself, your patients at risk of having a pretty bad complications. So the problem with the post, here's another Josh Harris article. Again, he's the expert on that on complications, looking at 12,000 hips. And there's a lot of complications related to that post. You know, it would be putational nerve palsy or perineal soft tissue injury. And so I do think that, you know, using a post, you can be very careful if you're going to be using a post, how much traction you apply and for how long you apply it for. So again, post-free distraction, Omar Maydan over Colorado, probably the pioneer as far as creating post-free traction for us, but you can use post-free traction on standard tables as well, just because your hospital doesn't have some fancy attachment. You can just take the normal pink pad or sometimes your blue pads. Usually your OBGYN will have these pads as part of their setup. You can use that on a regular table and apply post-free traction on any regular table. Just read Josh's article. It's really quite good. This is what my, what it looked like for me. When I use the Smith and Nephew attachment, you can use, use any sort of friction pad on the, on the table. I currently use this table by Stryker, which is allows you to apply pretty good traction across the joint without using a post. It's called a Stryker Guardian. Know your anatomy, LFC in particular, because you're going to see this problem if you don't, if you're not careful. It's almost to the point where you see these things so commonly, we don't even call them complications, but that being said, if you can avoid having numbness on the outside of your hip, you'll have a happier patient overall. So neuropraxia, I usually use a nick and spread. And then what I'll do is I'll take my anterior portal. I'll move it a little bit more, excuse me, a little bit more laterally, a little more distally so that it's a little bit safer for that nerve. So when you're placing your anchors, so these are intraoperative issues you can be very aware of. There's a very, very different spots inside the joint will give you different trajectories as far as how you can place your anchors. And the so-called caution zone for me or for anybody, it's going to be that area just in front of the anterior inferior iliac spine down about the four o'clock position. So as you can see from this chart, your actual your safety angle there is pretty, it's pretty narrow. It's to be very careful about how you place your anchors in that position. What you don't want to do is you don't want to take your anchors and place them into the actual joint. So as you can see from this, this is kind of diversity that Brian Kelly did. If you have the angle incorrect, what will happen is you place that anchor, that anchor could actually be intra-articular or just beneath the actual articular cartilage. So be very careful with that. Additionally, if you bring your hand too far back, you actually can place your anchor into the psoas tunnel. That can also be an issue. So here's just a kind of a little, little schematic as far as what you're thinking about as you're doing this. I always watch the articular surface as I'm placing my anchor, as I'm drilling, because we want, you want that anchor to go dead center down the middle of that, that bony, that bony area right there. So it's in the middle of the bone and not in the joint. Again, if you lift your hand too high, so if you're coming too proximal from your portal, you place that same anchor, what will happen as you drill it, you might drill an anchor right into the articular surface. And a lot of times these hips you're treating will have a wave sign or have some type of articular cartilage irregularity. And you can place an anchor right into the actual joint and not even realize it. So be very careful as you're placing that anchor. You do not penetrate the articular surface. On the other side, you want to make sure you do not penetrate the medial cortex either. So if you didn't bring your hand too far back, what will happen is you'll, you'll, you can drop your hand into the medial cortex. If you want to make sure that you are in bone, what you can do is after you place your anchor, as you look at this video, you can place nitinol wire right down the middle of your cannula, and you can feel that bony bed at the bottom of it. That way, you know, you're in bone the whole entire way. You're not placing anchor into the pelvis. Um, this is the most important thing I think you can possibly get from this talk is you want to make sure you get your correction correct. Okay. The last thing you want to do is you want to have a bad cam correction. So there's no question, at least, uh, in the past 15 years or so, the reason we're doing a lot of revision hip scopes, because the bony correction was not good enough the first time around. Um, this is Cam Newton. Sadly, as he's retired, this is no longer going to be quite as a slide, but you want your camera to look good. So, um, uh, patients with a good camera section will do well. Okay. Unfortunately, camp can look quite bad. It can be quite ugly. So you can either undersect it, you know, just not do a good enough for section. You can over resect it, which might even be worse under a section because this is almost untreatable. We're just resected in the wrong place. This is one that's too proximal. Um, and even though they've decompressed that joint, they really haven't decompressed in the right place. And that's the hip. That's just not going to do well in the longterm. So in order to give a comprehensive thermoplasty, you want to make sure you've got good x-ray views and good visualization inside the joint. So again, it all starts to be able to see. So if you're trying to get that cam, and I know that, uh, the app that Josh Harris and the guys who will be talking, we talking about your capsulotomies, make sure you can see what you need to see. For instance, if you want to take care of this cam deformity, you got to be able to see it. Uh, in this case, we use a T cut capsulotomy in order to be able to see all the way down that neck in order to get the entire cam corrected. Avoid the apple bite. So this is what I call the apple bite. So this is a picture of a femoral, uh, head that was resected in the wrong place and create a little bite there. And as you can see, Ben Dome cut that out to put a total hip replacement in, because if you have your correction in the wrong place, you really can't do much with it in the original setting. So I took an apple up to my closet and made these, these, uh, these pictures. And all I'm doing is I'm shooting, uh, um, basically what's the equivalent of an x-ray. It's a light and looking at the shadow against the wall in the back of my closet. And as you can see in this apple, there's a massive apple bite taking out of this apple, but on the x-ray, which you can see it's a shadow in the back of the screen, it looks like a normal apple. Um, so if you've been burning for a while, you don't see any correction in your x-ray, you might be creating this apple bite. As you rotate this apple around, what you'll see is you'll see just the depth of that apple bite on your x-ray. And what you've realized that you've unknowingly created a large problem without even knowing you were doing it because your x-ray wasn't good enough. And so you'll see on the AP x-ray, it looks pretty good, right? But then when you go to your lateral x-ray, you'll see that you've really created this, this large, um, this large cutout of the hip. And that's, that's going to be, it's going to be very, very hard to correct in the revision setting. So as you're using your fluoroscopy and you're monitoring your correction, your, your instrument really should float on the deformity. So as you're placing that, the burr down on the deformity, you want to be able to see, um, it floating there because you know that if I burn that location right there, it will correct the deformity. If you're too far anterior, too far posterior, what you'll see is you'll see that it's not floating on there. If you burn that in that area, you might find yourself burring out bone. You can't recognize. And the last thing you want to do is just burn, burn, burn. So you see a correction because it might be too late. Um, so again, you'll use Florida to your correction. And you can see that as, if you just do it in the right plane, you'll see your correction in real time. Um, heterotopic ossification. I think most of us in this, on this faculty use some type of HO prophylaxis. I personally use an aproxine, 500 milligrams BID for 30 days. That's what Dr. Byrd was using. Um, as you can see from these articles, any type of NSAID utilization can decrease your HO, uh, incidence, uh, from, you know, higher number to a lower number. So, uh, be very careful with HO. Um, I don't see it often mainly because I prophylaxed, but if you do have HO, it can lead to a real bad issue going forward. Um, so as far as you don't want to see, um, you know, I actually think instability. So when you've actually done something to the joint to destabilize it is a big problem. So this is an article from Dr. Dean Matsuda, where he had a hip that actually dislocated and PACU. And when you start looking at why hips might dislocate or why you might lead to the instability after hip arthroscopy, a lot of the times what you'll see is a capsule is the most important thing. So unreported, unclosed capsulotomy, uh, leads to big problems. You'll see this in hips that are shallow, have dysplasia, um, hyperlaxia. Again, these are only nine cases, but you can kind of infer that these are the things you want to avoid, um, to have, uh, ischemic instability. But I also think that instability is not just the macro instability, it's the micro instability. What you'll find if you have, um, you know, hip that's not been taken care of from a stability standpoint is you'll find kind of these adhesions that form these capsular scarring that occurs. And what I think that most of us who do a lot of hip arthroscopy realize the capsule ends up being a really important component of how hips do well before, after surgery. So when I lie in bed at night, thinking about my hip scopes, the capsule is what keeps me up. I'm always trying to figure out how to do the capsule better. I was sitting with my fellow one day, Dr. Greg Anderson, who's now, who's a Mayo Clinic grad, and he was my fellow about two years ago, and he was sitting there eating a burrito. And I'm sitting there watching him eat that burrito. And the thing's just falling apart right from the get go. What I realized is he, he took out of the foil. He did not have a plan. He did not have a plan to eat that burrito. And it's just like capsular management. The moment you get into that hip joint, that's when capsular management really starts. It's about how you start your capsulotomy because what you want to do is create a good capsulotomy so you can close it there at the end. So you want to have nice clean edges. You want to have a nice, um, you know, a smallest possible capsulotomy. You want to do what you want to do. So at the end of the case, you're able to close it and close it anatomically. So you have a watertight seal. You basically want to recreate what you cut into at the beginning of the case. Um, a couple other things that you just be aware of abdominal compartment syndrome, always keep an eye on your pump pressure and your pump flow. And if you have an anesthesiologist who says the patient's not doing as well as they should be doing it during a hip scope, just be aware that this can happen with the water, uh, during your hip arthrosphere can actually lead you up into the interpelvic space actually goes retroperitoneal. A lot of times you'll see this if you're doing a leo psoas tendon release, um, where the water is basically gets into the actual perineal, uh, retroperitoneal space and creates an abdominal compartment syndrome. Um, so we kind of talked about everything from an intraoperative standpoint, uh, postoperative standpoint, really the big difference between good and great outcomes, the rehab, um, you want to be able to protect your appearance while restoring the joint motion. I start my therapy within one or two days after surgery. Um, you can use a CPM, you can use a, uh, stationary bike, whatever you want to do to, to avoid, uh, to avoid adhesions, but also be aware of your motion restrictions. You don't want to rip apart your capsulotomy or to rip apart your labrum repair, your ATCs, your therapist, end up being your best friends throughout this entire process. And so create a protocol, talk to your ATCs, talk to your therapist, make sure all everyone's on the same page to rehab safely. Um, be aware about expectations. A lot of times people have the labrum tear, they get it fixed. They think they're gonna go back to whatever it is they're trying to do. Um, like for instance, a lot of times label tears will occur in these sort of, uh, uh, ultra athletes, for instance, and all they want to do is run their 70 miles in order to do their ultra marathon. But what you have to be aware of is that, that you have to set those expectations and you might not be able to normalize their hip after surgery. Uh, this is what a Big Mac looks like on the, um, on the advertisement, but a lot of times this is what you end up getting when you actually go to McDonald's. And so setting expectations really is just a question of understanding that your expectations, your reality, really your ratio, that if you set expectations too high and deliver too low of a reality, you'll lead to patient disappointment. So be very aware of setting your expectations during the entire process. So hips don't have to be hard. Here's your patient. It's just like this Rubik's cube. You know, just, you just rotate the sides to form the positions shown and you've got a completed Rubik's cube. That's how hips can be sometimes. So I hope that this, this helped you guys understand, um, how to stay out of trouble inside the hip. And again, the payoff is definitely worth the struggle. And just a shout out to all my fellows over the years. And if you have any more questions, email me or reach out to me. So thank you very much.

hip arthroscopy

complications

preoperative planning

bony correction

capsular management

patient communication

hip arthroscopy procedures

intraoperative challenges

nerve injuries

cartilage damage

post-operative rehab strategies