Complications associated with traction on the hip during arthroscopy

Experimental assessment of pelvis slipping during postless traction for orthopaedic applications

BACKGROUND

The application of lower limb traction during hip arthroscopy and femur fractures osteosynthesis is commonplace in orthopaedic surgeries. Traditional methods utilize a perineal post on a traction table, leading to soft tissue damage and nerve neuropraxia. A postless technique, using high-friction pads, has been considered as a potential damage-free alternative. However, whether these pads sufficiently prevent patient displacement remains unknown. Thus, this study systematically assesses the efficacy of commercial high-friction pads (PinkPad and CarePad) in restraining subject displacement, for progressively increasing traction loads and different Trendelenburg angles.

METHODS

Three healthy male subjects were recruited and tested in supine and Trendelenburg positions (5° and 10°), using a customized boot-pulley system. Ten load disks (5 kg) were dropped at 15s intervals, increasing gradually the traction load up to 50 kg. Pelvis displacement along the traction direction was measured with a motion capture system. The displacement at 50 kg of traction load was analyzed and compared across various pads and bed inclinations. Response to varying traction loads was statistically assessed with a quadratic function model.

RESULTS

Pelvis displacement at 50 kg traction load was below 60 mm for all conditions. Comparing PinkPad and CarePad, no significant differences in displacement were observed. Finally, similar displacements were observed for the supine and Trendelenburg positions.

CONCLUSIONS

Both PinkPad and CarePad exhibited nearly linear behavior under increasing traction loads, limiting displacement to 60 mm at most for 50 kg loads. Contrary to expectations, placing subjects in the Trendelenburg position did not increase adhesion.

Intraoperative traction has a negligible time-dependent influence on patient-reported outcomes after hip arthroscopy: a cohort study

The aim of this study is to determine if post-operative patient-reported outcome measures (PROMs) are influenced by hip arthroscopy traction duration. Patients from a local prospective hip arthroscopy database were retrospectively analyzed. Four hip-specific PROMs were utilized: modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), Hip Outcome Score-Sports Specific (HOS-SS), and international Hip Outcome Tool (iHOT). PROMs were collected pre-operatively and 6 months, 1 year and 2 years post-operatively. Two cohorts were created based on a cut-off corresponding to the 66th percentile for our patient cohort. Analyses were completed for each PROM at each post-operative interval with univariable statistics. Multivariable statistics were examined to identify the variables that were predictive of achieving post-operative minimal clinically important difference (MCID) at the 2-year follow-up. Overall, 222 patients met the inclusion criteria. The mean age was 32.4 ± 9.4 years, and 116 (52.3%) were female. The average traction time of the study population was 46.1 ± 12.9 min. A total of 145 patients were included in the short traction cohort (65%) with traction times of <50 min (66th percentile). No significant differences were found regarding PROM scores or MCID achievement rates between both cohorts at any post-operative period. In multivariable analyses, achievement of MCID was predicted by a decrease in traction time for all PROMs and pincer-type resection for mHSS, HOS-ADL and iHOT. There was no difference in PROMs and MCID achievement between longer and shorter traction time cohorts. On multivariable analysis, a decrease in traction time is predictive of MCID for all PROM scores and pincer-type resection was predictive of MCID for most PROM scores. Level of evidence: Level III, cohort study.

Nerve Injuries Following Total Hip Arthroplasty: The Influence of Surgical Approach

Nerve injuries following total hip arthroplasty are rare but devastating complications. The most important modifiable risk factor remains the choice of hip approach and surgical technique applied. The risk of nerve injuries is related to technical complexity of the procedure and anatomic variability of the nerves. Surgeons should remain cognizant of inherent risk factors, variations in the course and branching patterns of different nerves, and technical considerations of the surgical approach to mitigate risks. This article reviews the literature on postsurgical nerve injuries following total hip arthroplasty and characterizes the influence of surgical approach on the risk of this complication.

Nerve lesions during arthroscopic procedure: a literature overview

Arthroscopy is more and more popular. Although minimally-invasive, it's not completely free of complications as nerves lesions which can be invalidating for the patient and frustrating for the surgeon with significant economic, psychological and medico-legal implications. The purpose was to review the literature about nerve injuries related to arthroscopy. A scientific literature review was performed in PubMed/Medline, including articles dealing with cases of iatrogen lesions of the peripheral nerves occurred during arthroscopic procedures. These lesions are mainly due to direct damage by nerve section while cutting for making the portals or during surgical maneuvers, or indirect damage due to traction or pressure mechanisms especially for errors in patient positioning. Also the tourniquet can lead to compression and ischemic nerve injury. Arthroscopy can cause both transient and permanent neurological lesions manifested with dysesthesia up to paralysis according to Seddon's classification in neuroapraxia, axonotmesis and neurotmesis. Incidence of complications in general and of nerve injuries during arthroscopy are reported by joint. A rigorous respect for surgical technique and all perioperative precautions, particularly in relation to the positioning of the patient, greatly reduce the risk of nerve injury. The suggested waiting time before surgical nerve revision is 6 months. In the meanwhile the patient should perform physiotherapy constantly and improvements should be evaluated with clinical examination and electromyography 15-20 days after the lesion, and thereafter at 3 and 6 months.

Functional Outcomes of Hip Arthroscopy for Pediatric and Adolescent Hip Disorders

Background

There is a paucity of literature on the use of hip arthroscopy for pathologic conditions in skeletally immature patients. Thus, the indications and safety of the procedure are still unclear. The purpose of this study was to investigate the safety and functional outcomes of hip arthroscopy for pediatric and adolescent hip disorders. We further attempted to characterize arthroscopic findings in each disease.

Methods

We retrospectively reviewed 32 children and adolescents with hip disorders who underwent 34 hip arthroscopic procedures at a tertiary care children's hospital from January 2010 to December 2016. We evaluated functional limitations and improvement after operation by using the modified Harris hip score (HHS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), subjective pain assessment with a visual analog scale (VAS), and range of hip motion as well as the complications of hip arthroscopy. Arthroscopic findings in each disease were recorded.

Results

Hip arthroscopy was performed for Legg-Calvé-Perthes disease (n = 6), developmental dysplasia of the hip (n = 6), slipped capital femoral epiphysis (n = 5), idiopathic femoroacetabular impingement (n = 6), sequelae of septic arthritis of the hip (n = 3), hereditary multiple exostosis (n = 2), synovial giant cell tumor (n = 3), idiopathic chondrolysis (n = 2), and posttraumatic osteonecrosis of the femoral head (n = 1). Overall, there was a significant improvement in the modified HHS, WOMAC, VAS, and range of hip motion. Symptom improvement was not observed for more than 18 months in four patients who had dysplastic acetabulum with a labral tear (n = 2) or a recurrent femoral head bump (n = 2). There were no complications except transient perineal numbness in five patients.

Conclusions

Our short-term follow-up evaluation shows that hip arthroscopy for pediatric and adolescent hip disorder is a less invasive and safe procedure. It appears to be effective in improving functional impairment caused by femoroacetabular impingement between the deformed femoral head and acetabulum or intra-articular focal problems in pediatric and adolescent hip disorders.

A Characterization of Sensory and Motor Neural Dysfunction in Patients Undergoing Hip Arthroscopic Surgery: Traction- and Portal Placement-Related Nerve Injuries

Background

There is a paucity of prospectively collected data as they relate to nerve injuries after hip arthroscopic surgery. Studies describing the relationship of neurological injuries to portal placement and the duration and magnitude of traction force with regular and standardized patient follow-up protocols are limited.

Purpose/Hypothesis

The purpose of this study was to characterize nerve deficits in a series of patients undergoing hip arthroscopic surgery as these deficits relate to axial traction and portal placement. It was hypothesized that in patients who presented without nerve deficits after surgery, the magnitudes of traction-related measurements would exceed previous recommendations based on expert opinion (<50 lb). Additionally, it was hypothesized that sensory disturbance would commonly be observed (≥16%) localized to the distal anterolateral thigh related to portal placement.

Study Design

Case series; Level of evidence, 4.

Methods

A total of 45 patients scheduled to undergo hip arthroscopic surgery between July 2012 and February 2014 were included in this study. Traction force was measured and recorded every 5 minutes during surgery, and patients were assessed by a physical examination for deficits in light touch sensitivity at all lower extremity dermatomes preoperatively and at 3 weeks, 6 weeks, 3 months, and 1 year postoperatively. Patients were also tested for strength deficits and rated on the manual muscle testing grading scale. Patients reported modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living and -Sport subscales (HOS-ADL and HOS-Sport, respectively), Short Form-12 (SF-12) mental and physical component summaries, and international Hip Outcome Tool-12 (iHOT-12) scores preoperatively and at 1 year postoperatively.

Results

Thresholds for maximum traction force, mean traction force, duration of traction, and traction impulse were 120 lb, 82 lb, 61 minutes, and 7109 lb·min, respectively, below which no patients presented with sensory or motor dysfunction thought to be related to traction. A minority (17.8%) of patients presented with highly localized, distal anterolateral sensory deficits suggestive of injuries related to portal placement, and 2.2% of patients presented with perineal numbness localized to the distribution of the pudendal nerve. All nerve deficits had resolved by 1-year follow-up.

Conclusion

This study suggests that it may be possible to apply more axial traction force for a longer duration than expert opinion has previously suggested, without significant and, in the majority of cases (82.2%), any traction-related short-term complications. Transient traction- and portal placement-related nerve injuries after hip arthroscopic surgery may be more frequent (31.1% in this study) than have been reported historically.

What Is the Risk Posed to the Lateral Femoral Cutaneous Nerve During the Use of the Anterior Portal of Supine Hip Arthroscopy and the Minimally Invasive Anterior Approach for Total Hip Arthroplasty?

PURPOSE

To determine: (1) What is the proximity of the lateral femoral cutaneous nerve (LFCN) to the anterior portal (AP) used in supine hip arthroscopy? (2) What is the proximity of the LCFN to the incision in the minimally invasive anterior approach (MIAA) for total hip arthroplasty? (3) What effect does lateralizing the AP have on the likelihood of nerve injury? (4) What branching patterns are observable in the LFCN?

METHODS

Forty-five hemipelves were dissected. The LFCN was identified and its path dissected. The positions of the nerve in relation to the AP and the MIAA incision were measured.

RESULTS

The AP intersected with 38% of nerves. In the remainder, the LFCN was located 5.7 ± 4.5 mm from the portal's edge. In addition, 44% of nerves crossed the incision of the MIAA. Of those that did not, the average minimum distance from the incision was 14.4 ± 7.0 mm. We found a significant reduction in risk if the AP is moved medially by 5 mm or laterally by 15 mm (P = .0054 and P = .0002). The LFCN showed considerable variation with 4 branching variants.

CONCLUSIONS

These results show that the LFCN is at high risk during supine hip arthroscopy and the MIAA, emphasizing the need for meticulous dissection. We suggest that relocation of the AP 5 mm medially or 15 mm laterally will reduce the risk to the LFCN.

CLINICAL RELEVANCE

These findings should aid surgeons in minimizing the risk to the LCFN during hip arthroscopy and the minimally invasive anterior approach to the hip.

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.

Pudendal nerve injury is a relatively common but transient complication of hip arthroscopy

PURPOSE

Hip arthroscopy is emerging as the standard of care for conditions involving the hip, and has a unique set of complications. The purpose of this review was to identify (1) the crude rate of pudendal nerve injury following hip arthroscopy and (2) the specific factors leading to pudendal nerve injury.

METHODS

MEDLINE, EMBASE, and PubMed were searched from database inception to October 2016. Patient demographics, indications, surgical technique, complication rates, treatment approaches, and rehabilitation strategies were extracted.

RESULTS

Twenty-four studies (n = 3405) were included, with the majority (66%) of studies being level IV evidence. The mean age was 33.9 ± 9.7 years (range 12-78) and 48.2% were males. Average follow-up was 30.2 ± 19.1 months. 62 patients were reported to have sustained pudendal nerve injury (1.8%) post-operatively, and all resolved within 6 weeks to 3 months. Of the seven studies that reported using a perineal post, 20 patients were diagnosed with pudendal nerve injury (4.3%), in contrast to two studies (189 patients) reporting only 0.5% pudendal nerve injury without the use of perineal post. Two studies commented on time of traction during surgical intervention with mean times of 98 and 68 min with complication rates of 10% and 6.6%, respectively.

CONCLUSIONS

Pudendal nerve injury is not uncommon following hip arthroscopy, with a reported rate found in this review of 1.8%. Potential risk factors may include the use of a perineal post and long traction times. All reported cases resolved within 3 months. Patients should be informed of complications related to pudendal nerve injury, which include sexual and urinary dysfunction.

LEVEL OF EVIDENCE

Level IV, systematic review of level I-IV studies.

Patient-specific factors influencing the traction forces in hip arthroscopy

INTRODUCTION

The application of traction in hip arthroscopy is associated with peri-operative complications. Within a therapeutic case series, patient-related factors correlating with high-traction forces during hip arthroscopy and occurring complications should be identified.

MATERIALS AND METHODS

In 30 male and 38 female patients (mean age: 44.5 years), intra-operative traction forces were monitored continuously using a specialised measurement device. A multivariate analysis was employed to identify patient-related factors influencing the traction force. Peri-operative complications (follow-up: 12 weeks) were evaluated by performing a single-case analysis.

RESULTS

The mean initial force prior to penetration of the capsule ("initial force") was 477 N (men: 517 N; women: 444 N), decreasing after capsulotomy by an average of 17 %. The male gender (p < 0.001), Kellgren and Lawrence radiographic stage (p = 0.037), low minimum joint-space width (p = 0.029) and high body height/weight (p = 0.003/0.037) correlated significantly with higher distraction forces. The patient age and type of anaesthesia (general versus spinal) were not relevant. Complications were observed in ten patients on the first post-operative day. In two of these patients a partial sensory deficit of the lateral cutaneous femoral nerve persisted after 12 weeks. All patients with complications required initial traction forces of >400 N.

CONCLUSIONS

The study revealed several patient-specific risk factors correlating with high-traction forces during hip arthroscopy. With view to potential complications, these patient groups require special attention during surgical treatment as well as in future studies.

Hip arthroscopy complications regarding surgery and early postoperative care: retrospective study and review of literature

PURPOSE

The purpose is to describe the rate of complications in a series of hip arthroscopies performed at our center, as well as perform a systematic review of the current literature in order to compare our outcomes.

METHODS

Two hundred and fifty-eight patients affected of femoroacetabular impingement and treated with hip arthroscopy have been studied. All minor and major complications were studied during the first postsurgery year. Furthermore, a systematic review was performed comparing major and minor complications with our series. Two attending orthopedic surgeons selected the different studies with the same inclusion and exclusion criteria, remaining with 48 studies that have been reviewed and included in the present study.

RESULTS

Mean age was 36.6 years old (SD 17.45), and the ratio men:women was 137:121. The mean complication rate observed was 14.34% (37/258) of global complications. Only three patients showed major complications: femoral neck fracture, septic arthritis and avascular necrosis of the femoral head. Any of these patients had permanent side effects.

CONCLUSIONS

Hip arthroscopy has a low rate of major complications, but a higher number of minor complications that could be avoided with certain preventive measures.

Surgical innovation and safety: femoroacetabular impingement and the IDEAL collaborative framework

Operative treatment of femoroacetabular impingement (FAI) is a relatively new, yet rapidly expanding surgical innovation. Although the practice of surgery is inherently innovative, there is no clear distinction between minor technical variation and true modification that warrants testing. This raises important questions about how new procedures should be evaluated before being broadly disseminated. The IDEAL Collaborative is a consortium that promotes safe and responsible translation of research into clinical practice. The collaborative has delineated the typical stages of evolution of new interventional technologies, and the type of study designs appropriate for each stage. This report examines the surgical treatment of FAI as a case study of the IDEAL framework and discusses both missed and future opportunities for critical assessment.

An arthroscopic safety zone for the medial compartment of the hip joint

The purpose of this study was to investigate the safety zone without any neurovascular injury to the medial compartment of hip joint through an anatomical method and describe the relationship of the extra-articular anatomic structures from the surface of the hip joint. Thirty-two fresh specimens from 17 adult Korean cadavers (8 males and 9 females, age range 54-79 years at death) were used for this study. For the measurements, the most superolateral point of the pubic symphysis (PS) and prominent point of the anterior superior iliac spine (ASIS) were identified before dissection. The line connecting the PS and ASIS was defined as a reference line and the PS was a starting point for measurements. All 19 variables measured in this study were related to the femoral head, neck, and surrounding neurovascular structures. The variables were measured according to the x- and y-coordinates in relation to the reference line. The femoral head was generally located 39.5-71.0 mm on the x-coordinate and located 33.5-34.6 mm on the y-coordinate. The junction of the femoral neck and body was located at 52.8 mm on the x-coordinate, and 65.3 mm on the y-coordinate. The junction of the femoral head and neck was located at 47.1 mm on the x-coordinate, and 51.4 mm on the y-coordinate. The location of the medial compartment of the hip joint was located from 38.0 to 43.0 % on the x-coordinate and located from 5.1 to 6.5 cm. These results of this study provide detailed anatomy for arthroscopic hip surgeons.

Pudendal nerve neuralgia after hip arthroscopy: retrospective study and literature review

INTRODUCTION

Pudendal nerve neurapraxia is a classic complication after traction on the fracture table. Diagnosis, however, is difficult and often overlooked, especially after arthroscopy in traction on fracture table; incidence is therefore not known exactly.

HYPOTHESIS

The study hypothesis was that incidence of pudendal nerve neuropathy exceeds 1% after hip arthroscopy.

MATERIALS AND METHODS

Results for 150 patients (79 female, 71 male) undergoing hip arthroscopy between 2000 and 2010 were analyzed retrospectively. The principal assessment criterion was onset of pudendal neuralgia. Secondary criteria were risk factors (history, surgery time, type of anesthesia), associated complications, onset to diagnosis interval and pattern of evolution.

RESULTS

At a mean 93 months' follow-up, there were 3 cases (2 women, 1 man) (2%) of pure sensory pudendal neuralgia; 2 concerned labral lesion resection and 1 osteochondromatosis. Surgery time ranged from 60 to 120min, under general anesthesia with curarization. Time to diagnosis was 3 weeks. No complementary examinations were performed. Spontaneous resolution occurred at 3 weeks to 6 months. No significant risk factors emerged.

CONCLUSION

The present study found 2% incidence of pudendal neuralgia, with no risk factors emerging from analysis. Prevention involves limiting traction force and duration by using a large pelvic support (diameter>8-10cm). Patient information and postoperative screening should be systematic.

LEVEL OF EVIDENCE

Level IV. Retrospective study.

Access to the hip joint from standard arthroscopic portals: a cadaveric study

PURPOSE

Our purpose was to study and describe the areas of the hip joint that can be safely visualized and operated on using a variety of portals for the central and peripheral compartments.

METHODS

Twelve hip joints in 6 human cadavers were examined through 9 different central and peripheral arthroscopic portals. Markings of the accessible areas within the joint were made through an arthroscope. Dissection of the cadavers was carried out for final evaluation of the visible areas and those accessible for instruments. During dissection, anatomic proximity of the portals to relevant neurovascular structures was measured.

RESULTS

The central compartment was sufficiently accessible using the anterior, anterolateral, and posterolateral portals, with slight limitations in the posteromedial corner. A more medial portal did not offer substantial advantages regarding accessibility but decreased the safety distance to the femoral nerve. With regard to the peripheral compartment, the combination of the anterolateral and posterolateral portals allowed visualization of most of the joint. It was observed that the structure at highest risk of injury for the central anterior and the peripheral anterolateral portals was the lateral femoral cutaneous nerve.

CONCLUSIONS

In hip arthroscopy, the use of the standard anterior, anterolateral, and posterolateral portals allows proper accessibility of the central compartment, with slight limitations in the posteromedial corner. A more medial portal is not recommended with regard to its risk-benefit ratio. The peripheral compartment of the hip joint is sufficiently visible using the anterolateral and posterolateral portals. For treatment of specific pathologic conditions, a variation of these portals improves surgical accessibility. The anatomic structure at highest risk of injury during hip arthroscopy is the lateral femoral cutaneous nerve.

CLINICAL RELEVANCE

The general objectives of this study were to prepare surgeons to develop appropriate concepts of surgery and to facilitate preoperative planning.

Complications of arthroscopic surgery of the hip

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.

Labral penetration rate in a consecutive series of 300 hip arthroscopies

BACKGROUND

Intraoperative labral injury during the establishment of the first portal in hip arthroscopy has been reported to be as high as 20%.

PURPOSE

The purpose of the study was to prospectively identify the incidence of acetabular labral injuries that occurred while using a current technique for the establishment of portals during hip arthroscopy.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Between the years 2008 and 2010, data were prospectively collected for all patients undergoing hip arthroscopic surgery. Patients with previous labral resection or Tonnis grade greater than 1 were excluded. Patients were positioned supine, traction was applied, and portals were established. The anterolateral portal was created first by venting the joint with a spinal needle and then re-entering the joint with the same needle with the bevel side facing the labrum. Next, the midanterior portal was created under vision. A thorough examination of the acetabular labrum was conducted arthroscopically through multiple viewing portals, and labral injuries related to the establishment of portals were identified and noted.

RESULTS

A total of 300 patients were included in the study; only 2 patients (0.67%) suffered intraoperative labral injuries at the study period. One injury occurred during revision arthroscopy, while the second involved a hyperplastic labrum in a dysplastic hip. No patient with normal hip morphological characteristics undergoing a hip arthroscopy suffered a labral tear as a result of portal placement.

CONCLUSION

The incidence of iatrogenic labral injury during hip arthroscopy can be as low as 0.67% when using the described technique.

Avascular necrosis of the femoral head after hip arthroscopy

We report a case of a 61-year-old woman who underwent hip arthroscopy for a labral tear. The acetabular labrum was resected arthroscopically. Three months later, magnetic resonance imaging showed avascular necrosis of the femoral head. Theoretically, avascular necrosis following hip arthroscopy may result from traction on vessels supplying the femoral head, direct injury to such vessels during portal entrance, raised intra-articular pressure, prolonged operating time and damage to vessels during bony resection or osteochondroplasty for femoroacetabular impingement. We presume that avascular necrosis in our case was a result of a traction injury and increased intra-articular pressure.

Is a hip distractor useful in the arthroscopic treatment of femoroacetabular impingement?

INTRODUCTION

There is increasing interest in using hip arthroscopy for the treatment of femoroacetabular impingement (FAI). However, the distraction is typically done with a traction table, which can lead to complications. Our working hypothesis was that a hip-specific distractor could be used to perform arthroscopic treatment of FAI without the complications associated with traction.

MATERIAL AND METHODS

Twenty-three patients were included in this prospective study with an average follow-up of 21 months (range 12-28 months). The average age was 34 ± 4 years. The technical feasibility, complications, quality of the distraction and early clinical results were evaluated.

RESULTS

None of the arthroscopy procedures had to be converted to an arthrotomy. In all cases, the procedures planned for the central and peripheral compartments were fully executed. One patient (4%) had a grade 1 cartilage iatrogenic injury of the femoral head. The distraction was determined to be effective in all the patients, with an average of 15 mm of distraction achieved (range 12-21 mm). The average Merle d'Aubigne score went from 11 (range 9-18) preoperatively to 16 (range 14-18) postoperatively; the average Harris score went from 76 (range 46-80) to 91 (range 87-100); the average Christensen score went from 64 (range 48-88) to 84 (range 72-100); the average Womac score went from 58 (range 42-96) to 84 (range 74-100). No neurological, infectious or bone complications were recorded.

DISCUSSION

The use of a distractor during hip arthroscopy appears to be a reliable and reproducible technique that allows FAI to be treated. Early results are consistent with those reported in the literature, and the risks associated with the use of a traction table are reduced. This technique makes hip arthroscopy safer and contributes to advances in labrum and cartilage repair, without additional complications.

LEVEL OF EVIDENCE

Level III prospective study.

Case report: Osteonecrosis of the femoral head after hip arthroscopy

BACKGROUND

Hip arthroscopy is a common orthopaedic procedure used as a diagnostic and therapeutic tool with a multitude of surgical indications. The complication rate is reportedly between 1.3% and 23.3%. Major complications are related to traction, fluid extravasation, and iatrogenic chondral injury. Although osteonecrosis is a concern with any surgical procedure about the hip, this complication has been primarily a theoretical concern with hip arthroscopy.

CASE DESCRIPTION

We report the case of a 24-year-old man who presented with a 2-year history of left hip pain. He underwent hip arthroscopy to include débridement of a torn labrum and removal of a prominent pincer lesion for femoroacetabular impingement. Traction was initiated by applying manual traction to the traction bar until 10 mm of joint distraction was obtained. Traction was removed at 90 minutes. At the 3-month followup, MRI showed osteonecrosis in the subcapital region of the left femoral head.

LITERATURE REVIEW

It generally is agreed the magnitude and duration of traction during hip arthroscopy increase the risk of traction-related injuries. Only one previous case of femoral head osteonecrosis associated with hip arthroscopy has been reported, and this may have resulted from the initial traumatic event. Based on anatomic studies, the use of standard arthroscopic portals would not put at risk any dominant normal vascular structures supplying the femoral head. In contrast, the literature shows that femoral head osteonecrosis may develop secondary to a combination of increased intraarticular pressure and traction.

PURPOSES AND CLINICAL RELEVANCE

We suspect this case of femoral head osteonecrosis after hip arthroscopy was caused by traction used in the procedure.

Do complications in hip arthroscopy change with experience?

PURPOSE

The aim of this study was to evaluate the type and incidence of complications during the development of hip arthroscopic techniques.

METHODS

A retrospective series of 194 files of patients treated with hip arthroscopy in a tertiary hospital from December 1999 to March 2008 was reviewed for complications. The incidence of complications was recorded consecutively for each group of 30 patients and in intervals of 2 years. A comparison between the complication rates was performed within the time frames and the set of cases. The type and severity of complications were also recorded.

RESULTS

There were 12 complications (6.1%) in this series. Of these, 5 were neurologic (2.6%), 4 were musculoskeletal (2%), and 3 were vascular/ischemic (1.5%). According to severity, 2 were considered major complications (1%), 8 were intermediate (4.1%), and 2 were minor (1%). The incidence of complications did not change with time (P = .959) or with the number of cases performed (P = .771), but different types of complications occurred along the learning curve.

CONCLUSIONS

The nature of complications changed with experience, but no significant variation in the incidence was observed over the 9-year period of experience with hip arthroscopy.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Variations in serum electrolyte concentrations and renal function after therapeutic hip arthroscopy: a pilot study

PURPOSE

The purpose of this study was to analyze changes in serum electrolyte concentration and renal function after hip arthroscopy.

METHODS

We studied 10 consecutive patients (4 men and 6 women; median age, 30.5 years [range, 20 to 50 years]) undergoing hip arthroscopy. Operating time, traction time, and perfusion volume of lactated Ringer solution (in milliliters) were recorded. Preoperative and postoperative levels of sodium (Na(+)), potassium (K(+)), cloride (Cl(-)), calcium (Ca(2+)), magnesium (Mg(2+)), phosphorous (P), creatinine, and blood urea nitrogen (BUN) were compared.

RESULTS

The median operating time was 80 minutes (range, 60 to 150 minutes). The median perfusion volume of lactated Ringer solution was 15,000 mL (range, 6,000 to 30,000 mL). The median traction time was 37.5 minutes (range, 30 to 105 minutes). None of the patients had postoperative complications develop. With a mean decrease of 0.84 +/- 0.68 mg/dL, only serum calcium levels were found to decrease significantly (P = .01). There was a mean decrease of 1.50 +/- 2.07 mEq/L in sodium concentrations (P = .06). Hip arthroscopy was associated with a mean postoperative decrease in creatinine and BUN concentrations of 0.05 +/- 0.06 mg/dL (P = .19) and 9.84 +/- 10.36 mg/dL (P = .13), respectively. Although the mean decrease in BUN concentration was important, this was not shown to be significant. No correlations were found between operating time, perfusion volume, and postoperative changes.

CONCLUSIONS

Lengthy therapeutic hip arthroscopy under high intra-articular pressure has only a minimal effect on electrolyte balance and renal function. We therefore conclude that performing routine preoperative and postoperative blood analysis of electrolyte concentrations and renal function is unnecessary.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

Hip arthroscopy: current concepts and review of literature

Diagnosis and treatment of intra-articular hip problems in young patients present a challenge to hip surgeons. Previous studies have shown that non-invasive investigations such as radiography, computed tomography and magnetic resonance imaging provide limited help. Non-operative treatment is likely to result in persistent symptoms, and surgical options for intra-articular hip problems involve open arthrotomy of the hip joint, which carries potential risks associated with joint dislocation. Arthroscopy of the hip joint, therefore, seems to be an attractive option. It was once thought that introduction of a straight arthroscope into the ball-and-socket hip joint was almost impossible. Hip arthroscopy has seen several advances since then, and the speed at which it developed in recent years directly corresponded to the rate at which the conditions affecting the hip joint were identified. Athletes and other young individuals with hip injuries are increasingly being diagnosed with an ever evolving series of conditions. Many of these conditions were previously unrecognised and thus left untreated, resulting in premature ends to the patients' competitive careers. Hip arthroscopy, as with any procedure, is not without risks. The procedure is not widely available as it requires specialist equipment and takes a long time to learn. Complications are few, occurring in <5% of patients.