This is Dustin Richter and Christopher Canario from the University of New Mexico, and we'll be discussing management of the struggling patient following hip arthroscopy. Our disclosures can be found on the Academy website. When evaluating the struggling patient, I find that it helps to get a timeframe on when they began having problems. With these patients who never had any improvement after surgery and never did well, hopefully this is a very small group of patients, but someone that you have to look for other sources of pain. Was there global undercoverage that was unrecognized? Did they have pain more so coming from their back or neurogenic symptoms? Patient who did well but then had gradual worsening of symptoms is a fairly common scenario. This can be a patient who develops iliopsoas tendonitis or possibly adhesions. Patient who does well with acute worsening of symptoms, you have to see if there was any injury noted. They could have a failure of their capsular repair or failure of their labral repair with an ink or pullout. Patients who did well for one to two years and then pain returned may have some recurrence of their labral tearing or a potentially incomplete resection of any underlying impingement. Another common group is a group that slowly improves but just not as quick as they would like. Frequently, these patients need some education and reassurance regarding overall expectations and the length of recovery. It's important to talk with patients about their postoperative course. Did they participate in physical therapy? Were they able to go to this? Did they have appropriate resources at home? How were they with their postoperative restrictions with avoiding some of the extremes of motion to protect both their labrum as well as their capsule? What are the patient's symptoms that they come in with? Is it pain? Is it pain in the same area? Are they experiencing more mechanical symptoms with locking or catching? Is it numbness or tingling? Or do they have subjective instability of the hip that they can no longer trust? When identifying the source of pain, as we all know, it can be a variety of sources and you really have to figure out is this an intra-articular or extra-articular source. So beginning with the history as well as the physical exam, where's the location of their pain? Is it in the anterior groin region, posterior buttock region, lateral, or somewhere else? What do they have pain with? If they have pain with resisted straight leg raise and it's fairly severe at the six-week to three-month mark, that points us towards more of an iliopsoas tendinitis type picture. It's important to always rule out infection, although this is rare. You want to evaluate the patient's incisions, any warmth or constitutional symptoms, and evaluate their motion. Did they have good motion and then it became less and less, which may point towards adhesions in the hip? Or did they have a sudden increase in motion with pain, which may point to more of a capsular integrity issue? When you evaluate for capsular integrity, always look at the patient's Baton score, see if there's any hip dysplasia noted, and then there's a variety of instability tests that can be done. This is the anterior apprehension test with hip extension, external rotation at the foot, and then an anteriorly directed hip force, which may cause some pain or apprehension. The iliofemoral bounce test has been described as well. When you look at this video, it shows that when capsular insufficiency is present, a lack of bouncing will be observed due to unrestricted external rotation of the hip to constrain the hip joint. Additional workup that may be needed includes labs to rule out infection or inflammatory arthropathies. Imaging is always an excellent place to start as well. Radiographs can rule out fracture, rapid joint collapse, or heterotopic ossification. With an MRI, it's important to consider an MRI orthogram in the setting of a failed hip arthroscopy to evaluate both the integrity of the labrum, but also to evaluate for capsular integrity. CT scan, if this has not been done in the preoperative setting, can be done with a CT scanogram or a limited hip to knee to evaluate for femoral aversion, and then several companies have a proprietary software that can help map the hip joint and evaluate for any missed or underlying impingement or unrecognized overcoverage or undercoverage of the hip socket and retroversion changes. And then once again, it's always important to evaluate for other sources of pain with appropriate referrals as needed. So once again, this does require a broad differential as it can be spine related or more pain in general related. This is an example of some of the postoperative imaging. So radiographs on this patient preoperative as well as six months postoperatively showed a rapid joint collapse. Infection was ruled out with labs as well as an aspiration of the hip, and the patient did end up going on to need a total hip arthroplasty. In this setting, CAM lesion preoperatively is shown with appropriate resection. However, the patient developed heterotopic ossification despite chemoprophylaxis with naproxen. This can require resection if the patient continues to have pain and problems. It's not uncommon for patients to also form fairly dense capsulolabral adhesions, which frequently show up around the three to six month mark. So for treatment plan, education and reassurance is what the majority of patients need, letting them know that it can take a year and a half to two years based on studies that have shown patients reach their maximum outcomes with patient report outcome measures in this time frame. It's important to manage expectations, and if patients are significantly better, you can let them know that they may or may not have complete relief of their symptoms, but hopefully they have achieved a reasonable improvement. You can renew physical therapy for these patients. Consider diagnostic and therapeutic corticosteroid injections. Patients with iliopsoas tendinitis frequently will benefit from this, and also patients who have developed some adhesions or maybe stirred up some scar tissue can benefit from an interarticular injection. Alternative treatment modalities include chiropractic treatment, acupuncture, massage therapy, which a subset of patients may benefit from. Pain management for nerve ablation or other treatment modalities is important. Getting a second opinion from one of your colleagues, whether it's within your practice or outside of the practice, never hurts and gives the patient another set of eyes on their hip, which many patients will appreciate. And then considering a revision hip arthroscopy for suspected etiology with some of the most common ones being lysis of adhesions. If there is a re-tear or poor quality labrum, doing a revision repair versus reconstruction, and also appropriate management of the capsule. This is a patient who had dense capsulolabral adhesions requiring lysis of adhesions. Patients may also have re-tear requiring either revision repair or reconstruction. I prefer to use a tibialis anterior allograft for my reconstruction patients. And lastly, with capsular management, I prefer a pants over vest capsular imbrication that is anterior based involving the iliofemoral. And if you look at this video, this shows one of our sutures that had been placed. We will place another one, but it's imbricating the proximal leaflet over the distal leaflet. Thank you for your attention on the management of the struggling patient and good luck in your practice.

hip arthroscopy

pain management

iliopsoas tendonitis

patient education

corticosteroid injections