For this ANA toolkit, we will be discussing the evaluation of the failed hip scope. Here are our disclosures. Following hip arthroscopy, patients are expected to undergo a standard rehabilitation protocol to properly protect the joint and minimize inflammation. Strengthening progresses gradually with a strong emphasis on endurance and building a solid foundation. By phase 4, patients can begin to see a return to prior functional activities and return to sport. At 6 months, patients can be evaluated for an official return to sport, which is determined based on how patients are doing with strength, flexibility, and pain-free movement. So when does a hip arthroscopy fail? One case is if patients continue to have residual pain, functional limitations, or cannot return to work or sport despite completing the appropriate rehab. These patients have typically tried additional conservative treatments like physical therapy, medications, and injections without success. It's also important to remember that recovery can take up to one year, especially in higher demand individuals, so patient counseling and continued follow-up beyond the 6-month mark is key. There are several reasons a hip arthroscopy may fail. First, an inaccurate or incomplete diagnosis can leave the true problem unaddressed. Second, some conditions are more complex than anticipated, requiring more extensive procedures than initially performed. Third, incomplete resolution of the issue, such as residual bony impingement, unclosed capsule, or residual labral tears can lead to persistent symptoms. Fourth, underlying patient factors like arthritis, instability, or poor healing can limit recovery. Finally, inadequate rehabilitation or failure to follow recovery protocols can compromise outcomes. When evaluating a failed hip arthroscopy, imaging can be helpful when properly indicated. X-rays can help identify over or under resection of can or pins from morphology. MRIs, especially with contrast, can assess the capsule and labrum, although early post-op MRIs are often hard to interpret. Many times, a repeat MRI should be done if patients continue to have residual symptoms more than a year after surgery after failing conservative treatment. Finally, CT scans may be helpful to better evaluate acetabular coverage and version. Intraarticular injections can also be an important evaluation tool to determine if patient symptoms are originating in the hip joint. Injections into surrounding structures, like the trochanteric bursa, the glute media minimus, hamstrings, SI joint, can also help rule in or out extraarticular sources of pain. Ultimately, injections can help guide whether or not to proceed with further intraarticular treatment options or if attention should be turned towards the other structures in the hip. Following the optimization of underlying comorbidities and ensuring a primary intraarticular pain generator, common surgical treatment options in revision hip arthroscopy include lateral repair or reconstruction, femoroplasty to address residual CAM lesions, and managing capsular defects if instability is present. We'll present a case to highlight the decision-making process in the case of a failed hip scope. Our patient is a 41-year-old female with a history of diabetes who presents with a persistent sharp groin pain and dull lateral hip pain about three years after prior left hip arthroscopy. She has been compliant with therapy, attending twice a week, but reports minimal improvement. On exam, her range of motion shows flexion to 100 degrees, external rotation to 20 degrees, and internal rotation to 15 degrees. She has positive Faber and Fader tests with painful arc between 1 and 3 o'clock, but full strength and no tenderness over surrounding hip structures. Her last MRI was over a year ago and done without contrast, so we recommended obtaining an MRI arthrogram for better evaluation of her hip joint. Radiographs show normal S-tandard coverage and evidence of a prior CAM resection. On MRA, a degenerative labral tear can be seen with evidence of capsular inflammation and adhesions. In addition to the MRA, a diagnostic intraarticular injection was performed. She found moderate relief for a few days, but found these injections to interfere with her sugar control. Given her physical exam imaging and positive response to an intraarticular injection, it was determined that the degenerative labral tear and capsular adhesions and inflammation to be contributing to her failed postoperative course. She has exhausted conservative measurements, and thus the plan was to perform a revision hip arthroscopy with either repair or reconstruction of the labrum and capsule. In summary, preoperative patient selection and diagnostic workup is key to ensure patients are properly indicated for hip arthroscopy. Failure to do so may lead to unresolved symptoms and a difficult postoperative course. In addition, imaging and injections can be helpful tools to help isolate intraarticular pathology and help guide potential surgical treatment further down the road. Finally, it is important to outline patient expectations prior to surgery and counsel that it may take up to one year after surgery to start seeing meaningful results. Thank you for listening to this talk.

hip arthroscopy

rehabilitation

diagnostics

revision surgery

patient selection