Avoiding Failure in Hip Arthroscopy: Complications, Pearls, and Pitfalls

Clinical and Radiographic Predictors of Acetabular Cartilage Lesions in Adolescents Undergoing Hip Arthroscopy

BACKGROUND

Acetabular cartilage lesions are a known cause of poor outcomes after hip arthroscopy and are seen regularly among adolescents. However, studies identifying preoperative factors predictive of acetabular cartilage lesions have been limited to adult populations.

PURPOSE

To assess clinical and radiographic predictors of acetabular cartilage lesions in a large cohort of adolescents undergoing hip arthroscopy.

STUDY DESIGN

Cohort study (Diagnosis); Level of evidence, 3.

METHODS

Patients undergoing hip arthroscopy for idiopathic femoroacetabular impingement or acetabular labral tears at a children's hospital were reviewed. Demographic predictors were analyzed by use of univariate logistic regression with generalized estimating equations. A matched case-control analysis was subsequently performed to identify radiographic predictors of acetabular cartilage lesions through use of univariate and multivariable conditional logistic regression.

RESULTS

Four hundred two patients (446 hips) undergoing hip arthroscopy between 2010 and 2015 were analyzed. Median age was 16.7 years (range, 13.6-19.0) and 72% of patients were female. Ninety-five hips (21%) were found to have an acetabular cartilage lesion at the time of arthroscopic surgery. Age (odds ratio [OR], 1.7; 95% CI, 1.4-2.1), male sex (OR, 2.5; 95% CI, 1.7-5.0), and body mass index (OR, 1.07; 95% CI, 1.01-1.14) were found to be predictive of intraoperative acetabular cartilage lesions. In the matched case-control analysis, femoral alpha angle as calculated on a Dunn lateral radiograph was independently predictive of an intraoperative acetabular cartilage lesion (OR, 1.8; 95% CI, 1.2-2.6). Additionally, the presence of a crossover sign was independently associated with a decreased odds of an acetabular cartilage lesion (OR, 0.3; 95% CI, 0.1-0.7). On multivariate analysis, alpha angle (Dunn lateral) (OR, 2.0; 95% CI, 1.3-3.1) and crossover sign (OR, 0.2; 95% CI, 0.1-0.7) remained independently associated with the presence of an acetabular cartilage lesion. The presence of an acetabular labral tear was not predictive of an associated cartilage lesion (OR, 1.17; 95% CI, 0.39-3.47; P = .78).

CONCLUSION

In an adolescent population undergoing hip arthroscopy, older age, male sex, and higher body mass index were predictive of acetabular cartilage lesions. From an imaging standpoint, increased alpha angle increased the likelihood of an acetabular cartilage lesion whereas the presence of a crossover sign decreased this likelihood. Predicting the presence of an acetabular cartilage lesion is important when considering a hip arthroscopy procedure to facilitate preoperative planning and to more accurately set patient expectations.

Surgical Trends in Arthroscopic Hip Surgery Using a Large National Database

PURPOSE

To assess the practice trends in hip arthroscopy, including femoroplasty, acetabuloplasty, and labral repair Current Procedure Terminology, 4th edition (CPT-4), codes that have been implemented since many of the previous studies were published, without concerns for Hawthorne or observer effect as can be seen during a board collection window, and in a larger volume of patients with a more comprehensive database than previous published data.

METHODS

The MarketScan Commercial Claims and Encounters database was searched using CPT-4 codes to identify patients who underwent any arthroscopic hip procedure from 2008 to 2013. Patients identified were characterized by gender, age group, and year of the initial procedure. Regression analysis was used to evaluate differences in surgical trends between individual patient groups delineated by age and gender. The Cochran-Armitage trend test was used to identify significant differences in surgical trends seen yearly.

RESULTS

A total of 62,782 arthroscopic hip procedures in 31,569 surgeries in 27,997 patients were identified and included from 2008 through 2013. The number of surgeries in the database increased every year. After changes to CPT coding in 2011, femoroplasty became the most common procedure in 2012, comprising 28% of all procedures performed in 2013. Patients ages 40 to 49 underwent the most procedures (7,467, 27%). Females were more likely to undergo any arthroscopic procedure during the study period (.068% vs .041%, P < .0001). A total of 2,754 patients (10%) underwent a second surgery during the study period. A total of 1,625 patients (6%) underwent a total hip arthroplasty following an arthroscopic procedure during the study period.

CONCLUSIONS

Arthroscopic hip procedures continue to increase, with femoroplasty, labral repair, and acetabuloplasty being the 3 most common procedures performed. Females are more likely to undergo any procedure, and labral repair is now performed more commonly than labral debridement.

LEVEL OF EVIDENCE

Level IV, cross-sectional study.

Postoperative Numbness: A Survey of Patients After Hip Arthroscopic Surgery

Background:

Hip arthroscopic surgery is a rapidly growing procedure that requires distraction of the leg to access the joint. A frequently reported complication of this procedure is postoperative numbness, with rates between 1% and 20% reported in the literature.

Purpose/Hypothesis:

The purpose of this study was to determine the factors contributing to the development and effect of numbness on functional outcomes. We hypothesized that this complication is underreported and that its prevalence is higher than what has been described in the literature.

Study Design:

Case series; Level of evidence, 4.

Methods:

Patients who had undergone hip arthroscopic surgery between 2012 and 2016 were included, and a telephone survey was conducted to collect data. Data related to the procedure and outcome scores were collected via a systematic chart review for the included patients. Data analysis was conducted for means, SDs, frequencies, and percentages. For comparative statistics, t tests and multiple logistic regression models were used.

Results:

A total of 221 patients (113 male, 108 female; mean age, 39.8 ± 13.34 years) completed the survey out of 362 eligible patients. Overall, 37% (n = 82) of patients reported having experienced some form of numbness after surgery. Approximately 43% (35/82) of the patients reported resolution by 6 weeks postoperatively, and 68% (56/82) of numbness was reported to have completely resolved by 6 months. The duration of surgery was a significant factor for the development of postoperative numbness (P = .010; odds ratio, 2.18) when comparing procedures longer than 50 minutes with procedures shorter than 50 minutes (first incision until closure). Postoperative numbness was associated with a negative effect on the International Hip Outcome Tool–33 (iHOT-33) score that reached statistical significance at the 1-year (numbness, 60.19; no numbness, 74.21; P = .006) and 2-year time points (numbness, 52.04; no numbness, 72.69; P = .01).

Conclusion:

This study confirmed our hypothesis that postoperative numbness is more common in our patient population than the incidence reported in the literature. This adverse event was also shown to be associated with decreased postoperative functional outcomes, as measured by the iHOT-33 at 1 and 2 years postoperatively.

Editorial Commentary: With New Technology Comes New Responsibility: Do the Complications of Hip Arthroscopy See Us More Often Than We See Them?

A database study of the codes for hip arthroscopy reports a rate of major and minor complications that is higher than previously reported in the literature. The relative risk of conversion to hip replacement or a subsequent fracture or dislocation is greater than in the general population.

Imaging evaluation of the hip after arthroscopic surgery for femoroacetabular impingement

Arthroscopic surgery for femoroacetabular impingement (FAI) is increasingly frequently performed. Initial reports were that complications were very low, but as experience has increased, a number of long-term complications, in addition to factors related to poor clinical outcomes, have been identified. This review describes the normal and abnormal postoperative imaging appearance of the hip after arthroscopy for FAI. Abnormalities discussed include incomplete resection or over-resection of the impingement lesion, heterotopic ossification, cartilage damage, chondrolysis, instability and dislocation, recurrent labral tear, adhesions, psoas atrophy, infection, and avascular necrosis.