Rehabilitation After Hip Arthroscopy

Rehabilitation after hip arthroscopy has not been well understood in the past. While surgical procedures continue to advance, athletes are already pushing the limits to return to competition as quickly as possible. As postoperative protocols evolve, it is essential to follow the basic guidelines of rehabilitation. Initially, soft-tissue healing constraints must be considered while focusing on controlling swelling and pain, restoring ROM, and preventing muscle atrophy. As physiological healing occurs, rehabilitation must address progressive lower-extremity strengthening, proprioceptive retraining, and sport-specific training.     

Hip Arthroscopy: Surgical Indications

Successful outcomes of hip arthroscopy are most clearly dependent on selecting appropriate patients. The indications are numerous and continue to evolve. These indications are summarized in this report. The anatomic architecture of the hip region imposes unique challenges to performing this procedure. As a surgeon’s experience evolves, so will his or her indications for this operation. It is imperative to be knowledgeable about the technique, to exercise care with the procedure, and to be certain that it is being performed for proper reasons.     

Abdominal Compartment Syndrome After Hip Arthroscopy

As hip arthroscopy becomes a more common procedure, more complications may occur. We present a case of abdominal compartment syndrome resulting from fluid extravasation in a 42-year-old man who underwent routine hip arthroscopy for femoral acetabular impingement. He had not had previous surgeries to that hip, and arthroscopy was performed in the supine position. After adequate distraction, arthroscopy was performed with an automated pressure- and flow-controlled pump with the pressure maintained between 40 and 60 mm Hg. We performed debridement of a degenerative tear of the anterosuperior labrum, removal of a pincer lesion, and a psoas tenotomy through a capsular window. A distended abdomen was noted on drape removal, and the patient required decompressive laparotomy for abdominal compartment syndrome. Extravasation of arthroscopy fluid is a potentially devastating complication during hip arthroscopy, and there should be careful monitoring by the surgeons, anesthesiologists, and operating room staff.     

Hip Arthroscopy: Applications and Technique

Hip arthroscopy is infrequently performed in North America. The anatomic constraints of the joint and the lack of equipment specifically designed for this application have contributed to the lack of surgical experience. Because of the potential for significant neurovascular injury, familiarization with precise portal placement is essential. In properly selected patients, hip arthroscopy allows diagnosis of a variety of disorders. The authors believe this technique has a significant role in the treatment of acetabular labral tears, loose bodies, chondral injuries to the joint, and septic arthritis.     

Ultrasound-Guided Establishment of Hip Arthroscopy Portals

We describe ultrasound-guided establishment of hip arthroscopy portals. The surface projections of anatomic structures around the hip joint (including the nerve, vessels, femoral neck, and acetabulum) were marked. The entry points were then planned for the anterolateral and anterior portals and, if necessary, the posterolateral portal. The anterolateral portal was first placed. Through the use of real-time ultrasound guidance, a pin was inserted into the hip joint and 20 mL of normal saline solution was injected. A K-wire was then inserted into the joint space over the needle. The arthroscopic trocar was introduced along the K-wire, and the arthroscope was inserted to confirm the establishment. The anterior portal was then established. The hip joint was flexed slightly. The previous procedure was duplicated to insert the K-wire. The path of the pin was confirmed by viewing from the arthroscope in the anterolateral portal. If necessary, the posterolateral portal was established by the same procedure.     

Abdominal Fluid Extravasation During Hip Arthroscopy

Hip arthroscopy has gained popularity in recent years as an alternative to open treatment for several conditions including bursitis, acetabular labral tears, synovitis, arthritis, extraction of loose bodies, and femoroacetabular impingement. Complications during hip arthroscopy are rare in the current literature, but reports include venous thromboembolism, peripheral nerve injury, septic arthritis, instrument failure, and various problems associated with joint traction. Extravasation of fluid into the abdomen during hip arthroscopy is another rare but known complication. We report an occurrence of extravasation of fluid into the abdomen during arthroscopic treatment of femoroacetabular impingement and our management of the condition postoperatively.     

Anterior Hip Dislocation 5 Months After Hip Arthroscopy

Hip dislocation subsequent to hip arthroscopy is a rare complication. We report on a case of low-energy anterior hip dislocation that occurred 5 months after hip arthroscopy, a period notably longer than any previously reported event. The patient was a track and field athlete who presented and received treatment for a labral tear and cam lesion. The athlete then dislocated her hip postoperatively during competitive jumping, a motion that requires significant hip flexion and extension. The most likely cause of the anterior dislocation was failure to close the capsule at the completion of surgery, lending credibility to recent trends in the literature suggesting routine capsular closure. We believe that a partial psoas release also contributed to dynamic hip instability because of increased femoral anteversion in this patient. This case suggests that hip capsule closure should be considered at the completion of every procedure and that a psoas release should be avoided in patients with significant anteversion. Furthermore, the biomechanics of competitive jumping may make these athletes more prone to dislocation and require more conservative return-to-sport recommendations.     

Editorial Commentary: The First Hip Arthroscopy Is the Best Hip Arthroscopy,Capsular Defect or Not

Hip arthroscopy has evolved significantly over the last 5 to 10 years. With this comes the burden of patients with continued pain after their index procedure. Reasons for the need for revision surgery can be many, including incomplete resection of impingement morphology, unrecognized/unaddressed acetabular dysplasia or hip instability, failure to manage the soft tissue appropriately (i.e., labrum or capsule/ligament), or other unrecognized cause of pain, like femoral retroversion or subspine impingement. Like many other orthopaedic procedures, revision hip arthroscopy with or without a defect in the hip capsule has significantly worse outcomes at 2 years compared with primary hip arthroscopy. This emphasizes the importance of proper diagnosis, well-done surgery, and proper rehabilitation the first time to avoid the need for revision hip surgery in the young adult altogether.