Complications of hip preserving surgery

Abstract

Preoperative evaluation of the pathomorphology is crucial for surgical planning, including radiographs as the basic modality and magnetic resonance imaging (MRI) and case-based additional imaging (e.g. 3D-CT, abduction views).Hip arthroscopy (HAS) has undergone tremendous technical advances, an immense increase in use and the indications are getting wider. The most common indications for revision arthroscopy are labral tears and residual femoroacetabular impingement (FAI).Treatment of borderline developmental dysplastic hip is currently a subject of controversy. It is paramount to understand the underlining problem of the individual hip and distinguish instability (dysplasia) from FAI, as the appropriate treatment for unstable hips is periacetabular osteotomy (PAO) and for FAI arthroscopic impingement surgery.PAO with a concomitant cam resection is associated with a higher survival rate compared to PAO alone for the treatment of hip dysplasia. Further, the challenge for the surgeon is the balance between over- and undercorrection.Femoral torsion abnormalities should be evaluated and evaluation of femoral rotational osteotomy for these patients should be incorporated to the treatment plan. Cite this article: EFORT Open Rev 2021;6:472-486. DOI: 10.1302/2058-5241.6.210019.

Keywords: SCFE; femoroacetabular impingement; hip arthroscopy; hip dysplasia; periacetabular osteotomy; surgical hip dislocation.

Fig. 1

A 34-year-old patient presented with postoperative hip pain following arthroscopic rim trimming and labrum refixation in an external institution. (A) Anteroposterior pelvis view shows a preserved joint space and no obvious deformity. (B) Computerized tomography of the hip showed a drill hole and suspected intraarticular position of the anchor. (C) Patient underwent subsequent surgical hip dislocation which confirmed the intraarticular anchor position and resulting co-located acetabular cartilage damage.

Fig. 2

(A) Preoperative anteroposterior pelvis view of a 27-year old professional football player with cam femoroacetabular impingement who underwent arthroscopic cam resection. (B) Ten months following return to play, the patient presents with recurrent hip pain. The corresponding radiograph shows no obvious pathology. (C) The coronal fluid sensitive magnetic resonance image of the hip shows bright bone marrow oedema with sclerotic line corresponding to a stress fracture. (D) Stabilization of the stress fracture was performed using cannulated screws.

Fig. 3

(A) A 26-year-old female patient with borderline developmental dysplastic hip and persistent hip pain following two external hip arthroscopies with offset correction and labrum debridement. Anteroposterior (AP) pelvis view shows insufficient acetabular coverage with an lateral centre edge angle (LCE) of 18°. (B) Magnetic resonance arthrography was performed for evaluation of intraarticular lesions. Radial images show hypoplastic labrum with intrasubstance tearing (arrow). Contrast interposition (arrowheads) at the posterior inferior acetabulum, corresponding anterior translation of the femoral head indicative for hip instability. (C) AP pelvis view six months after periacetabular osteotomy shows improved lateral acetabular coverage with an LCE of 27°.

Fig. 4

(A, B) A 33-year-old patient with normal acetabular coverage and mild cam deformity and partial labrum tear (arrow) anterosuperiorly who underwent arthroscopic cam resection and labrum refixation. (C) Patient presented with prolonged pain postoperatively and repeated magnetic resonance arthrography showed extensive defect of the anterior capsule (arrowheads). The patient was scheduled to capsule reconstruction subsequently.

Fig. 5

A 24-year-old patient with persistent pain after surgical hip dislocation for mixed femoroacetabular impingement. Magnetic resonance arthrography presents adhesions between the joint capsule and the femoral neck (arrowheads). The patient underwent hip arthroscopy for adhesiolysis.

Fig. 6

(A) A 39-year-old patient with developmental dysplastic hip (lateral centre edge angle (LCE) of 15°) and preserved joint space. (B) Six weeks postoperatively following periacetabular osteotomy, LCE was 28°. (C) Anteroposterior pelvis view shows nonunion of the osteotomy and stress fracture of the inferior pubic ramus six months postoperatively. (D) A decortication and re-osteosynthesis was performed via ilioinguinal approach.

Fig. 7

(A, B) A 41-year-old patient with history of Legg-Calvé-Perthes disease presenting with hip pain. Anteroposterior (AP) pelvis view and three-dimensional computerized tomography (3D CT) reconstruction show acetabular dysplasia with a prominent downsloping anterior inferior iliac spine (AIIS, white solid line) and coxa breva and magna. The anterior acetabular wall (AW) is shown in red, the posterior acetabular wall (PW) in blue. (C, D) The patient underwent subsequent periacetabular osteotomy and surgical hip dislocation with relative femoral head lengthening and offset correction. Six months postoperative, the patient presents with persistent pain and limited range of motion. The postoperative X-ray (C) and 3D reconstructed CT (D) show increased acetabular retroversion (positive crossover sign) and pronounced projection of the AIIS (white solid line) leading to intra- and extraarticular impingement. (E) Postoperative image after decompression of the too prominent AIIS and rim trimming via ilioinguinal approach.

Fig. 8

(A, B) A 14-year-old boy presenting with hip pain and unstable moderate slipped capital femoral epiphysis (Southwick angle 43° shown in B). (C, D) Magnetic resonance imaging was performed showing joint effusion and bone marrow oedema at the femoral neck but no signs of femoral head necrosis. (E) Postoperative anteroposterior pelvis view six weeks after modified Dunn procedure. (F) Four months postoperative, patient presents with increased pain and radiographic signs of flattening femoral head indicative for avascular necrosis of the femoral head.