My name is Richard Van Tienderen and Dr. Westerman and I would like to thank ANA for the opportunity to contribute this section on complications of hip arthroscopy to the ANAHIP toolkit. Dr. Westerman has the following disclosures. We hope that by learning about a few of these complications, it may help decrease the amount of them you have to experience yourself. Surgical treatment of femoral acetabular impingement, or FAI, has tremendous potential to help patients and has been shown to lead to high patient satisfaction and rates of return to sport in several prospective multicenter randomized controlled trials. As with any surgery, in order to optimize the surgical outcome, properly identifying surgical indications is of paramount importance. As Dr. Salter once stated, decisions are more important than incisions. In addition, the technical competence to perform the surgery properly is also key to getting the desired outcome. However, as with any surgery, both intraoperative and postoperative complications may occur. In this review article published in 2015 by Weber, they reported a generally low overall complication rate of 8% with temporary neurologic issues, iatrogenic cartilage or labral injury, heterotopic ossification, and capsulolabral adhesions identified as some of the most common complications. We will discuss these four common complications of hip arthroscopy. Neurologic injuries associated with hip arthroscopy can come in the form of distraction type, compression type, or penetration type injuries. Distraction type injuries more often involve the sciatic or femoral nerves and usually resolve within hours after surgery. Compression type injuries are associated with the use of a perineal post for joint distraction and the pedendal nerve is at greatest risk. As we will discuss on the next slide, postless distraction is effective at alleviating this type of nerve injury, but if a perineal post is utilized, it is important that it is well padded and that traction time and force are minimized. The lateral femoral cutaneous nerve is most often implicated in penetration type injuries and is at risk during portal placement. To avoid this, portal incisions should be made through the skin only with subsequent careful blunt dissection through the subcutaneous fat. This article published in AJSM in 2014 compared complications associated with joint distraction with and without a perineal post. 87 hip arthroscopy cases were included. 53 were performed with a perineal post while 34 with postless distraction. Growing numbness was present postoperatively in 30% of the post group versus none in the postless group. Three patients in the post group also reported postoperative sexual dysfunction. Joint numbness was also significantly higher in the post group. Continuing on the topic of post versus postless surgery, this article published in Arthroscopy in 2021 noted that total operative time, traction time, and OR time were shorter in the no post group with similar pain scores noted in PACU. Postoperative time to discharge was also shorter in the no post group. Iatrogenic cartilage and labral injury is another common complication of hip arthroscopy. Iatrogenic labral injury is at high risk during creation of the anterolateral portal. In order to mitigate this risk, fluoroscopic guidance should be utilized during portal creation and attention should be given to the labral shadow as well as the articular cartilage during needle localization. Optimal portal placement and advanced surgical technique are necessary to mitigate the risk for iatrogenic cartilage injury during hip arthroscopy. In 2015, Weber noted a 3% rate of iatrogenic cartilage injury. However, that rate was likely significantly underreported. So in Arthroscopy in 2020, Westerman published an article which attempted to report a more accurate rate of iatrogenic cartilage injury. The methods for this study involved analyzing videos published in Arthroscopy Techniques or VUMETI for evidence of iatrogenic cartilage injury. It was noted that the rate of injury identified by these videos may still represent an underreported rate or a best case scenario as these videos were ones that the surgeons were choosing to publish. Here are some examples of the iatrogenic cartilage injuries identified. In total, 94 videos were analyzed. The incidence of iatrogenic cartilage injury in total was just under 78%. Only minor injury was noted in approximately 58% of cases, whereas 36% noted intermediate damage and 7% noted major iatrogenic cartilage injury. Clearly, precise surgical technique is critical to ensure that the integrity of the cartilage is not compromised. Next we will discuss the complications of postoperative adhesions in capsular injury. Adhesions occur when the body deposits extracellular matrix and collagen in excess during the healing response, leading to fibrosis and scar formation. Adhesions between the capsule and labrum can cause pain and decrease range of motion. In addition, they can compromise the function of the labrum by pulling the labrum away from the femoral head, which may result in a loss of the suction seal mechanism, resulting in a feeling of hip instability. In 2023, Westerman published a systematic review regarding capsular labral adhesions. It was noted that the incidence of adhesions was low after primary hip arthroscopy with a range of 0-7%. However, the incidence was much higher after revision hip arthroscopy with rates as high as 25%. Anchor type was not a factor in the development of adhesions. Lysis of adhesions was noted to significantly improve patient reported outcomes. This video demonstrates the technique for release of capsular labral adhesion with arthroscopic cautery. Care is taken to release the adhesions and create an interval between the capsule and labrum while not causing significant injury to either structure. Here we see pictures from before and after the release of the adhesions. Often no further labor repair or reconstruction is needed following the lysis of adhesions. Here we see that the hip joint is able to achieve good suction seal following lysis of adhesions. Multiple strategies have been proposed to decrease the formation of capsule labral adhesions including early incorporation of hip range of motion with manual hip circumduction or CPM use. Non-resisted cycling can begin as early as post-op day one and aquatic therapy can also begin early on in recovery. Losartan has also been proposed as a prevention strategy for developing adhesions due to its modulation of transforming growth factor beta-1 which is a key cytokine in the formation of fibrosis. Further study on its efficacy is warranted. This case involves a 40-year-old female that sustained a fall approximately four weeks after hip arthroscopy at an outside institution and had continued pain and dysfunction six months post-operatively. MR arthrogram of the hip was notable for disruption of the hip capsule. A residual cam deformity was also noted. She was taken to the operating room for a revision hip arthroscopy with correction of her residual cam deformity as well as a repair of the disrupted capsule. The capsule was successfully closed and the patient was able to recover function post-operatively. Heterotopic ossification is another well-known post-operative risk of hip arthroscopy. The use of NSAIDs has shown excellent results in decreasing the risk of this complication. In this double-blind randomized controlled trial completed by Dr. Aoki, patients were placed on naproxen or a placebo after hip arthroscopy and it was found that heterotopic ossification developed in 46% of the placebo group versus only 4% of the naproxen group. Drs. Westerman and Willey published this article on the rates of heterotopic ossification after combined hip arthroscopy and open periacetabular osteotomy and found a less than 1% rate of heterotopic ossification with the use of naproxen. They also found that highly muscular males had a higher risk of developing heterotopic ossification. This is a case of a 19-year-old male basketball player that was noted to have worse pain in motion at six months postoperatively than he had been experiencing preoperatively. X-rays demonstrated a large area of heterotopic ossification that had developed around the hip joint. 3DCT was utilized to help further delineate the extent of the heterotopic ossification. He was taken to the operating room for arthroscopic removal of the heterotopic ossification. Fluoroscopic imaging was utilized for localization of the heterotopic ossification to assist with instrument placement and to confirm a complete removal was performed. An arthroscopic burr was utilized to excise the heterotopic ossification until a normal capsular layer was identified. The patient went on to do well. To help prevent further recurrence of heterotopic ossification, he was treated with a short course of indomethacin, as well as received a single dose of radiation on post-operative day one. Early motion and hip circumduction were also encouraged. One-year post-operative x-rays did not demonstrate any recurrence. As discussed earlier, appropriate surgical indications and technical performance of the surgery are necessary to optimize patient outcomes and decrease the risk of complication or need for revision surgery. This is a case that demonstrates improper surgical indications. The patient was an 18-year-old female dancer with chronic right hip pain. She had been treated one year earlier with an arthroscopic labor repair with no benefit. Imaging demonstrated severe hip dysplasia with a lateral center edge angle of 12 degrees. She had a diverging fear index indicating the presence of hip instability. She was indicated for periacetabular osteotomy to correct her acetabular coverage. Technical performance is also critical in maximizing patient outcomes. This case involves an 18-year-old male football player who had no benefit after primary hip arthroscopy. He was noted to have a residual cam deformity with an alpha angle of greater than 80 degrees. He underwent revision hip arthroscopy with femoral osteochondroplasty to fix his cam type impingement and restore a normal femoral head-neck offset. Residual impingement has long been known to be the primary cause of surgical failure for femoral acetabular impingement. While under-correction of the impingement deformity is important, it is also important to keep in mind the catastrophic consequences of over-correction as well. In conclusion, postless arthroscopy can prevent compression type neurologic issues, and it is important to utilize superficial skin incisions with blunt dissection to decrease penetration type nerve injury. Iatrogenic cartilage and labral injuries are more common than anyone wants to admit, and careful portal placement as well as innovative tools are warranted to avoid this complication. Capsular adhesions result in pain and loss of motion and can disrupt the suction seal mechanism of the hip joint. Early motion and balsartan may be strategies to limit this complication. Use NSAID prophylaxis in all cases of hip arthroscopy and keep in mind that risks are higher in muscular males. Thank you.

hip arthroscopy

neurologic injuries

surgical techniques

complication prevention

outcome optimization