I'm Mark Philippon, we'll be talking about capsular deficiency. And then Andrea Spiker was going to be talking about open management of bony issues, so when do you do osteotomies. Unfortunately, Andrea is not able to make it, but she did pre-record her lecture for you today. So there are many causes of failed hip arthroscopy, and we're going to focus really on the salvageable causes, both non-operative management as well as operative management of some of the more common causes. We're not going to focus on non-arthroscopically solvable issues, such as poor patient selection. That would qualify as people who wear sunglasses indoors during the evaluation, or the 40-year-old gentleman who comes in with his mother for the evaluation and management. We're not going to talk about the management of advanced osteoarthritis, or things like extra-articular impingement. So for me, I have this checklist, if you will, when I see a patient with failed hip arthroscopy. First of all, you want to determine if it was a well-done surgery or not, and if it was, then why did it fail? So we look at rehabilitation issues, are they stiff, do they have things like general stiffness or adhesions or limited motion in certain planes, are they weak, do they have tendonitis, as potentially reasons why they have persistent pain after hip arthroscopy. Then you want to make sure, was it the right diagnosis to begin with? Was the pain actually intra-articular to begin with? Do we know that for a fact ahead of time, and is the pain that they have now the same or different than what they had preoperatively? Do they have other things that might mimic intra-articular sources of pain? You know, the common hip flexor or iliopsoas issues, hamstring dominance, and we'll talk about that as that relates to iliopsoas type of pain. Or just referred pain from somewhere else, so is it the muscles around the joint, periticular issues, or are they elsewhere and just referred towards the hip? And then there's obviously under and over resection of FAI types of surgery, as we're seeing that more and more frequently, and we know that under resection or untreated FAI was the number one cause of failed hip arthroscopy in many papers. And then I think a thing that's actually occurring more and more frequently, certainly in my practice I see it very often, is actually failed hip arthroscopy due to instability that they may have had preoperatively and might have been missed or not recognized as a component of their problem. Could be that it was post-op, was it caused iatrogenically, or do they have some soft tissue deficiency that has resulted in hip instability? A week ago I was with, or two weeks ago I was with Mark Philippon and Brian Kelly at the Herodicus meeting, and Brian actually had published, just set out to publish a series of 229 revision hip arthroscopies, and I asked him to share this data because I thought it was very interesting and, again, more reflective of what I'm seeing and not what's in the literature. The number one cause of failed hip arthroscopy in his practice was impingement, particularly residual CAM impingement or subspinous impingement that may have been missed, and he found that in two-thirds of his patients. But in almost 15% of his patients, he found that they had instability of the hip, so that's something that hadn't been discussed in papers 10 years ago at all. And he found that 12.5% of his patients actually had capsular defects. He also found that heterotopic ossification was not an insignificant cause or need for revision hip arthroscopy, and I think we've come a long way. I know Mark Philippon early on really harped on the concern about adhesions and aggressive early, or getting earlier range of motion to help reduce the risk of capsular labral adhesions or peripheral compartment adhesions, and you can see this is fourth in the series in the top four causes of need for revision hip arthroscopy. So when I look at the stiffness in the patients, the question is, is it incomplete rehab? Some surgeons don't believe in formal physical therapy. Some patients don't go to physical therapy, even if you've given them a prescription. Some they just don't have the time to adequately do it. I think it's an important part of the whole surgery process itself is the rehab. Some insurance companies don't provide adequate amounts of physical therapy, or sometimes you get an inexperienced physical therapist, and I can't speak enough about the importance of having a therapist that's used to treating non-arthritic hip problems, just like in anything else, a specialty or a special interest and experience, and it can be very helpful because sometimes it can be too aggressive, and a lot of times you'll see patients end up with tendonitis post-operatively, or they're not aggressive enough, and then they end up being stiff. So again, sometimes it's from not moving much after surgery, or they're in bracing for too long a period of time. I think when they are in braces for a prolonged period of time, or if they're actually on crutches for a prolonged period of time, they actually end up being a bit on the stiffer side, and once they start walking and have the brace off, they'll gain some of that motion back, but you've got to determine, is it general stiffness, or are you having adhesions from either capsule or labral junctions? So as you remember back, normally the capsule does not attach to the labrum, but it attaches to the acetabulum above the labrum, so there's normally a gap between the labrum and the capsules. They should move independently, or you can get it in the peripheral compartment, and certainly I've seen both of these. And the management of this is to start off with physical therapy, where you have the physical therapist do both traction as well as joint mobilization techniques, and I think with that, you can oftentimes get, if you catch it early, you can avoid an operation to get their range of motion back and make them happier. Here you can see, this is a really thick, dense adhesion in the peripheral compartment between the femoral neck and capsule in a girl that had FAI surgery, and then here's another one that you can see, a capsule adhesion, I'll show you a video of a little bit better one, where you have loss of that cleft between the labrum and the capsule itself. And so, here we just remove that adhesion, let me go back, sorry it was a short clip, it was pretty dense, thick adhesion, but here you can see, this is a focal adhesion between the labrum and the capsule, you can see that my radiofrequency probe is pushing on it, and so the capsule can't move independently from the labrum itself, and so here with the RF, we just went ahead right through that focused adhesions. This is one I had to look through a lot of my files to find one that was nice and focused like that, most of them are more general adhesions across. But again, you want to restore the separation between the labrum and the capsule to allow for independent mobility. So weakness, generally what I see in the individuals that come to me that have had minimal or no rehab that are still having issues, a lot of times they'll be weak in the gluteus medius and the iliopsoas, and I think those are some that we really need to focus on, and obviously part of the rehab program involves working on core as well. And so obviously you send them to the PT and you gradually, start slowly and gradually build on the iliopsoas, the core, the glute med, and work their way up. Tendonitis is something I see less frequently when I have a really experienced therapist treating my patients, I'm seeing less and less tendonitis, but tendonitis, the probably three most common locations of the tendonitis in your post-op hips are going to be your iliopsoas, that'll have pain patterns like this, your adductors, and then your piriformis. And oftentimes I see this with, again, when therapists are being pretty aggressive, and I really have to tell my athletes and say, you've got to back down, because if you go too fast, an iliopsoas tendonitis will slow the rehab down by a good month, and just caution them that they just want to go in a step-by-step fashion. But these are three that I see less frequently, I think probably when I still see most of these is iliopsoas, but probably piriformis and adductors were very common, especially earlier on, before we had all our therapists on board. And so obviously the management of these tendonitis is you want to back down on their strengthening, you want to work on stretching the muscle-tendon junction, give them anti-inflammatories, modalities, and I think there's a role for doing ultrasound-guided injections as well, for both diagnostic and therapeutic purposes, to get it to calm down, both with, I use a combination of lidocaine, ropivacaine, and corticosteroid, to get it to calm down and allow them to rehab. One of the more common causes, I think, is actually just, was it the right diagnosis to begin with? Certainly there are a lot of people who see a labral tear on the MRI, or FAI anatomy on the X-ray, and they assume that's where the patient's pain is coming from, and that was probably never where the pain was emanating from, and I think the real way to know that, and one of the standards I use in my practice is they get a preoperative injection with anesthetic to see if it eliminates their hip pain, or at least half of their hip pain. If it doesn't, then I've got to think that the pain's not coming from inside the joint. The caveat to that is that I usually use the injection at the same time we do MR arthrography, and we used to use gadolinium with the MR arthrography, and I know they put a very small amount of gadolinium, but gadolinium can be very painful in a patient's hip, and we actually found a series of 108 of our patients that had MR arthrograms with gadolinium that did not get pain relief, or got minimal pain relief with the injection, and then we had them reinjected either under fluoroscopic or ultrasound injections with just the anesthetic, and had significant pain relief, and then operated on them, and they actually did as well as the other patients that we generally do that didn't have the gadolinium sensitivity, but I do think it's a real deal, and so, again, a preoperative injection with an anesthetic I think can be helpful in making sure the pain is coming from inside the joint. Some things that it cannot be is, again, sometimes it's iliopsoas tendonitis, or hip flexor, because it sits right on the front of the anterior capsule and the labrum. Hamstring dominance is an issue. I know when my friends in New York call it glute inhibition, we call it hamstring dominance, where the patients fire their hamstring before the glute, and they try to extend their hip, and that can put an excessive load on the hip flexors itself, and cause some, again, anterior groin pain, or it could be referred pain. I actually had a patient that came from four hours away from here, saw me, I thought she needed an intra-articular injection to confirm that the pain was coming from inside the joint, could not get it for her on the same day, but her MRI showed a really torn up labrum. She had some chondral damage, clearly had some pincer impingement. She actually refused to get the injection, or come back and get the injection. She didn't want to drive four hours each way to get the injection. I couldn't get it for her on the same day. She did the surgery, and she was no better, and so had her six week mark, she was no better, changed therapists, because she was from a rural community. She came back at the three month mark, still not better, but we had held an injection slot for her. The injection didn't get rid of her pain. She actually had a femoral hernia, and again, you know, I thought we did really a nice job with the surgery, but I think, you know, even in experienced hands, you can be wrong, and so I think the injection of the joint can be very valuable. So again, I think, I can't understate that, either ultrasound or fluoroscopy guided. And so again, you know, just what I found, one of the things I found in talking with people is actually the difficulty that a lot of people have in trying to understand if the iliopsoas is a sort of source of pain. So I've spent some time with Per Homish in Denmark, who is kind of the king of the iliopsoas, and so just to kind of review how we evaluate for it, the iliopsoas sits just medial to the sartorius, and so you evaluate the tendon below the inguinal ligament at the, just medial to the sartorius, and you also can evaluate it in the right lower quadrant, or left lower quadrant, depending on which iliopsoas you're measuring for, because you can palpate the iliopsoas when they activate it. And so here's a video. The patient's placed in a flexion adduction external rotation position. They hold their leg there, so that brings out the sartorius. You palpate the sartorius and go over the medial edge while you have them relax their leg, and then you have them do a straight leg raise. And against your fingertips, you should feel the iliopsoas tap against your finger, and if that reproduces the pain, then I think you need to be concerned that the iliopsoas might be part of the issue. We also assess for seated hip flexion, because that's the flexion that isolates the iliopsoas itself, and see if they have good strength, and to see if it reproduces their pain. If somebody with iliopsoas tendinitis, it'll be weak, and they'll have pain doing it. And I think, again, a diagnostic injection under ultrasound guidance can be very valuable. There's a difference between doing an ultrasound-guided injection and a fluoroscopic-guided injection with the fluoro. They try to aim for the lesser trochanter, and the iliopsoas, they aim more closer to the joint, and so sometimes they don't always get it into the bursa when they're down by the lesser trochanter, so just another tip that can be helpful. And I always assess for hamstring dominance. So if you see this athlete here, if you watch, I've got my fingers, two fingers on his hamstring and two fingers on the glute. When I ask him to extend his hip, if you'll see, the hamstring actually moves first. So I don't know if you can see that, but he fired his hamstring. It's just a split second before, and what you want to do is do psoas pain when you correct their hamstring dominance, which is muscle re-education. And then, again, you want to make sure the lung lifts the differential diagnosis. We're not going to go over it, but, you know, if it's not articular, it could be the periarticular muscles, the low back, the GI, including hernias, and the GU tract. So again, I think getting at least 50% pain relief with the intraarticular injection, we usually test them. If I don't do the ultrasound guide injections, our PMR people do, and our radiologists do, so I have them test, again, for the psoas, test them for resistance to the deflection before and after the injection, or before and after the MRI, or doing it with the impingement test. And so I think that a 3D CT scan, when somebody's had prior work, bony work, I think can be very helpful, or if the anatomy's unclear. So this is a patient that was sent to me. I think trying to use this commercially available collision software can also be sometimes helpful to see where the residual impingement may be coming from. Is it the AIS or untreated FAI? So here you can see, as you bring this around, this person had his anterior CAM lesion removed, but anterior laterally, laterally was not. And so you can see also that the AIS looks like it might be a type 2 AIS. And so with this collision software, I think it can help give you an idea. I don't know about its help as far as from a surgical standpoint, but that hasn't been proven out yet, but I think to just give you an idea when you're trying to evaluate a patient that there may be some benefit to using this type of software with the CT scan. So here's a professional baseball player that had a FAI surgery, and was still having pain, and you can see that there's some regrowth that's causing some impingement, as we're looking and doing a dynamic assessment. So you can see where there's still some exposed bone and some regrowth areas. And then after we resect it, you can see that he's able to flex all the way up and no longer impinges. And then you can have over resection. So this is a patient that had, you can see a CAM lesion, but also was borderline dysplastic. This was an AP pelvis that I just cut down for size, but you can see that some of the acetabulum had been resected as well. And now this patient came back to me and he had pain, and this was something that I couldn't salvage, which was a resection now being made dysplastic. And then here's a big shark bite, if you will, taken out from the proximal femur as well, and that has, I think, potential issues as well. And then from the instability standpoint, you can have people that were loose-jointed before you started and maybe not recognized. I think the easiest way I got kind of clued into this is people that had absolutely what looked like normal bony into that 13%. When people said 86, 87% of people that had labral tears had bony dysmorphology like FAI or dysplasia. This may be the other 13% was the instability. So people with normal bony anatomy now, we certainly see FAI with instability as well. I think it's increasingly being seen, at least in my practice, particularly because I think people are better recognizing FAI and better treating FAI overall. But I also think that as surgeons, more experienced arthroscopists are doing more advanced FAI surgeries, they're being a little bit more aggressive with capsulotomies. So there's a picture shared by Tom Sampson, a drawing that he had made. And what we showed is that when you're doing a T-capsulotomy here, you're going to cut the iliofemoral ligament. That's based on some anatomic work that we've done. But also if you make that T-capsulotomy arm, if you go down and go past the head-neck junction, you're going to be cutting the zona obicularis as well. So you're cutting two major ligaments in the hip to be able to get that visualization. And I'm not sure that that's actually a good thing. When left open, I think that, as Shane knows, if you leave that open, you have a higher risk of patient failure surgically than if you close it. So the questions come down to, were they susceptible to begin with, but stable? And then the surgery made them unstable. So those people who are ligamentously lax, hypermobile, or maybe they had some labral tissue removed or capsule ligament tissue that was removed and or not repaired. It's not uncommon to see people with CAMFAI, but borderline dysplasia. And maybe the borderline dysplasia wasn't recognized or not appreciated its significance. And the capsule wasn't managed the way you might if you did recognize that there was this borderline dysplasia. And again, realize that dysplasia is not just two-dimensional. So it's not just a lateral center or a jangle. It's a three-dimensional problem. So they could have what looks to be a normal lateral center or jangle, but have a deficient anterior center or jangle and have instability from that. Or they might have a high tonus angle or roof index. And again, if there's a capsular or labral defect that is made at the time of surgery. So here's a patient that had some CAM lesion, but also had some borderline dysplasia initially that wasn't recognized. You can also have, again, people that just stretch out their capsules, microtraumatic overuse like your dancers might, or generalized ligamentous laxity. And again, you can have some that just where the capsule repair either failed or was never closed to begin with. And so our way to manage this, if there's a defect that's repairable or closable, is just put some stitches in and repair or close the capsule. And again, you'll hear more on this and particularly the capsular defects by Mark Philippon in a few minutes. But here's a case that was sent to me. A patient, here's her femoral head. Here's her labrum. Here's a capsule, and that's normally what you don't see. You don't usually see the iliopsoas there. So you have that defect, and we just went ahead and did a primary repair of the capsule back to the supraacetabular wall. So again, more on this from the young Dr. Philippon. And then, you know, there's the issues with the labrum. I mean, they may have had a prior labrectomy, they might have had a labral repair or reconstruction that's failed. And so the question about when do you do primary labral reconstructions is something maybe Dr. Lal can shed light on as well as to avoid the need for revision or, again, what do you do to reconstruct if maybe the labral repair has failed and erosified? And then the heterotopic bone, as I said, is rarely a source of pain. Again, in Brian's, Brian Kelly's series, it was 4.6%. But here's a rugby player that was sent to me post-tip arthroscopy, and you can see pretty significant HO there that's anterolateral. And you can see here on the CT scan. I think the small ones, the small flexibone are not a big issue. But something like this, you can see how that might cause some symptoms for him. And we took that out arthroscopically. I think you can address this arthroscopically. And we see less and less of this severe stuff because people are being put on non-steroidals after surgery to help prevent HO, but still occasionally patients will come. And here you can see I left a little fleck, but otherwise okay. And then there's the subspinous impingement and excessive femoral version issues that, again, not recognized you can treat. The femoral version issues, again, will be discussed in Andrea's talk. And subspinous impingement, you've got to look for it to find it. You won't necessarily see it on an AP and a lateral very well, but on a false profile and on your sagittal views on the MRIs and CTs, you'll be able to see that pretty well. So again, publications suggest revision hip arthroscopy is not, the results are not as good as primary, but I think if you can identify the cause, I think they can do actually pretty well. So you want to make sure that the issue is an intra-articular problem. You want to identify and treat the underlying cause of why they failed as well as potentially the primary source of pain. And then, again, oftentimes I'll see patients that it was not an intra-articular source that was causing their pain. Again, also I think instability is being recognized more and more frequently as a cause of failed hip arthroscopy. And again, I think if you approach the, treat the intra-articular source, that the outcomes can approach the primaries. So I thank you for your attention on this. I think next is A.J. Lowell.

hip arthroscopy

persistent pain

operative management

checklist

causes of failed hip arthroscopy

management strategies