Refractory pain following hip arthroscopy: evaluation and management

Abstract

With increased knowledge and understanding of hip pathology, hip arthroscopy is rapidly becoming a popular treatment option for young patients with hip pain. Despite improved clinical and radiographic outcomes with arthroscopic treatment, some patients may have ongoing pain and less than satisfactory outcomes. While the reasons leading to failed hip arthroscopy are multifactorial, patient selection, surgical technique and rehabilitation all play a role. Patients with failed hip arthroscopy should undergo a thorough history and physical examination, as well as indicated imaging. A treatment plan should then be developed based on pertinent findings from the workup and in conjunction with the patient. Depending on the etiology of failed hip arthroscopy, management may be nonsurgical or surgical, which may include revision arthroscopic or open surgery, periacetabular osteotomy or joint arthroplasty. Revision surgery may be appropriate in settings including, but not limited to, incompletely treated femoroacetabular impingement, postoperative adhesions, heterotopic ossification, instability, hip dysplasia or advanced degeneration.

Fig. 1.

Coronal (A), sagittal (B) and axial (C) view of 3-D CT hip demonstrating post-surgical changes (overly aggressive anterior resection) and inadequately addressed residual cam where the deformity is persistent laterally and distally. Additionally, this patient demonstrates borderline acetabular dysplasia. The 3-D CT can provide invaluable information for preoperative planning.

Fig. 2.

Treatment algorithm for failed hip arthroscopy.

Fig. 3.

Anteroposterior pelvis (A) and Dunn (B) views of a patient (same as in Fig. 1) with persistent right hip pain that presented to clinic for second opinion after index arthroscopic surgery. There is evidence of inadequately addressed impingement (e.g. residual cam distally and laterally; over-resection anteriorly) and borderline dysplasia.

Fig. 4.

T1 coronal (A) and oblique axial (B) MRA of the hip demonstrating a labral tear at the 1 o’clock position (A, blue arrow) and a suture anchor from prior surgery (B, blue arrow).

Fig. 5.

Adhesions often occur at the site of neck osteochondroplasty where there is good vascularity. When the adhesions form proximally in the area of the resected femoral neck, they can restrict motion and become symptomatic.