Often we will hear from people who have had a hip arthroscopic surgery who have continued pain following the procedure. These people are now in a situation where they have to decide on three different courses of action. Redo the surgery, find other treatment options, or just manage the pain and live with it. Many orthopedist surgeons will try to find ways to address these patient’s concerns without immediately going back to hip surgery.
What is causing the post-surgical pain?
According to some surgeons, the pain can be coming from sources that were present before the surgery. In some cases then, the surgery did not address the cause of the pain. These other sources of pain could be coming from the SI joint, the low back, the pelvic area or from Piriformis syndrome.
An editorial by F. Winston Gwathmey in the journal Arthroscopy (4) suggested: “The increasing use of hip arthroscopy has been accompanied by an associated increase in revision hip arthroscopy. The results of revision surgery are generally inferior to primary hip arthroscopy. When revision hip arthroscopy fails, repeat revision hip arthroscopy may be indicated. Addressing the etiology of failure of the primary and first revision surgery is fundamental to achieving optimal outcomes in repeat revision cases. Unfortunately, poorly executed previous surgery is the leading etiology of failure, with unaddressed femoroacetabular impingement, labral damage, and capsular deficiency most commonly encountered during repeat revision surgery.”
Reasons for hip arthroscopic failure
An October 2021 study reported overall complication rate in hip arthroscopy was 7.3% (67/908 cases), the minor complication rate of 4.9% (45/908 cases) and the major complication rate 2.4% (22/908 cases). The most common severe complications were iatrogenic cartilage damage and instrument breakage, while the most common minor complications were perineal hypoaesthesia (loss of feeling or numbness in the buttocks, thighs and groin area) and heterotopic ossifications. The conversion rate to total hip replacement was 4.2% (39/908 patients).
The wrong surgery
- The wrong surgery: Many patients who have failed hip arthroscopic failure suffer from hip osteoarthritis. A 2021 study (5) noted: “Most patients had pre-existing osteoarthritis and/or chondral lesions that became apparent at arthroscopy.” It was then that doctors realized a hip replacement may have been more suitable. Hip arthroscopy is typically not helpful for osteoarthritis. Despite many patients being recommended to the arthroscopic surgery.
The bone was not shaved down right or the cartilage and labrum is still or was damaged during the procedure
Not completely correcting a femoroacetabular impingement is the leading cause of failed hip arthroscopy.
A July 2021 paper in the journal Frontiers in surgery (1) discusses some of the aspects of a failed hip arthroscopy surgery:
“Hip arthroscopy is a reproducible and efficacious procedure for the treatment of femoroacetabular impingement syndrome. Despite this efficacy, clinical failures are observed, clinical entities are challenging to treat, and revision hip arthroscopy may be required.
The most common cause of symptom recurrence after a hip arthroscopy that leads to a revision arthroscopy is residual cam morphology as a result of inadequate femoral osteochondroplasty and restoration of head-neck offset, (this describes a procedure that shaves bone the neck of the femoral head or “ball” of the hip joint) though several other revision etiologies including progressive chondral (cartilage) and labral pathologies also exist. In these cases, it is imperative to perform a comprehensive examination to identify the cause of a failed primary arthroscopy as to assess whether or not a revision hip arthroscopy procedure is indicated.”
Femoroacetabular Impingement Syndrome is usually not an isolated diagnosis when the patient presents with chronic hip pain. It is part of a larger hip problem that can include muscle weakness and atrophy, advancing osteoarthritis, labrum tears, cartilage tears and ligament laxity or weakness. It is one or many or even all of these other factors that may contribue to post-arthroscopic hip pain.
Ligamentum teres tears
In this image, a tear of the ligamentum teres is shown.
The ligamentum teres is a somewhat thick, cord like structure that connects the femoral head (the ball) to the acetabulum (socket). It functions to help hold the ball of the joint in place within the socket. A tear of the ligamentum teres is often found in patients with co-conditions of femoroacetabular impingement and labrum tear.
From Wikicommons used under license attribution: (2016). “Imaging of Hip Pain: From Radiography to Cross-Sectional Imaging Techniques”. Radiology Research and Practice 2016: 1–15. DOI:10.1155/2016/6369237. ISSN 2090-1941. Author Article authors: Ruiz Santiago, Fernando; Santiago Chinchilla, Alicia; Ansari, Afshin; Guzmán Álvarez, Luis; Castellano García, Maria del Mar; Martínez Martínez, Alberto; Tercedor Sánchez, Juan
People with ligamentum teres tear typically feel pain when they do any activity that brings their knees towards their chin, such as walking up stairs, getting in and out of a car or chair. A compounding and confusing aspect of this type of injury is that it can cause a sensation of pain in the groin.
So why all the talk about the ligamentum teres?
There is a discussion in the medical community as to the importance or non importance of surgical reconstruction of the Ligamentum teres and its involvement in failed hip arthroscopic surgery.
An editorial commentary in the journal Arthroscopy (2) outlines these concerns:
“Ligamentum teres (LT) tears are correlated with hip instability, and biomechanical research suggests there is a stabilizing function of the intact native Ligamentum teres. With regard to Ligamentum teres reconstruction, currently, there are imaging studies demonstrating that the ligament goes on to heal and properly function. There are also no long-term clinical studies on the success rates of Ligamentum teres reconstruction. The clinical studies that have been done are done with a fairly high number of concomitant procedures, which makes it difficult to discern whether improvement can be attributed to the Ligamentum teres reconstruction. A recent review shows that after Ligamentum teres reconstruction, these very difficult patients can respond favorably to surgery two-thirds of the time. However, in the remaining one-third of patients, an additional surgery was required. . . For those not a candidate for periacetabular osteotomy , the patient should be educated on the risks of failure of Ligamentum teres reconstruction and have reasonable expectations, and the operation should be performed by an experienced hip arthroscopist with Ligamentum teres reconstruction.”
Traditional treatment options
As I mentioned above, surgeons will typically recommend a conservative non-surgical management plan for patients with persistent pain after failed hip arthroscopy. These treatments would include NSAIDs (anti-inflammatory medications), cortisone or corticosteroid injections and physical therapy. Patients would also be asked to avoid movement or activity that would aggravate their pain. This would include some exercises and stretching like yoga.
It should be pointed out that many of these conservative care options were used by the patient before they were recommended to surgery and it was the failure of these treatments that send them to hip surgery in the first place. It is because of this and the nature of post-surgical damage in the hip that these conservative care options fail at high rate and send the patient to a revision surgery.
Revision surgery is more challenging
A June 2020 paper reported the somewhat obvious. Revision surgeries are more challenging and not as successful as primary surgery. The paper’s author’s wrote: “As the rate of hip arthroscopy has increased there has been a relative increase in the rate of revision hip arthroscopy. The most common indications for revision hip arthroscopy include residual impingement, recurrent labral pathology, and instability. A careful history and physical exam should be completed to determine the timeline of symptoms and possible etiology, with advanced cross-sectional imaging to support the diagnosis. Multiple novel techniques have been developed to address the issues faced in revision hip arthroscopy. Though outcomes show improvement after revision hip arthroscopy, they are inferior to primary hip arthroscopy. Careful preoperative planning and appropriate patient expectations are essential.”
Part 2 More treatment options:
In the following articles I discuss our treatment options:
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1 Sullivan SW, Olsen RJ, Nwachukwu BU. Revision Hip Arthroscopy in the Native Hip: A Review of Contemporary Evaluation and Treatment Options. Frontiers in Surgery. 2021;8:237.
2 Hartigan DE, Hegedus CE. Editorial Commentary: Ligamentum Teres Reconstruction May Improve Hip Stability But Has High Revision Rates: Fad or Restoration of Function?.
3 Arakgi ME, Degen RM. Approach to a Failed Hip Arthroscopy. Current reviews in musculoskeletal medicine. 2020 Jun;13(3):233-9.
4 Gwathmey FW. Editorial Commentary: Repeat Revision Hip Arthroscopy: Unaddressed Femoroacetabular Impingement, Labral Damage, and Capsular Deficiency Are Commonly Encountered. Arthroscopy: The Journal of Arthroscopic & Related Surgery. 2021 Dec 1;37(12):3442-4.
5 Vesey RM, Bacon CJ, Brick MJ. Pre-existing osteoarthritis remains a key feature of arthroscopy patients who convert to total hip arthroplasty. Journal of ISAKOS: Joint Disorders & Orthopaedic Sports Medicine. 2021 Jul 1;6(4):199-203.