So I'm going to just talk about kind of my general overview, and we will have time for question and answer at the end. We'll ask, they are recording this, so if you have questions to come up to the microphone and ask the questions in the microphone. Also you'll get an evaluation about this ICL, so we always appreciate feedback about how we can make this better, and if you liked it, tell them you liked it. So my disclosures are on the Academy website and app. It's basically nothing that really is conflicting with what I'm going to be talking about. So we're going to start off with the evaluation of the patient with the failed hip arthroscopy, and I'm going to talk about the approach to managing some of the things about it and about the evaluation of the individual. As I said, Shane Ngo will be talking about labral deficiency, Mark Philippon about capsular deficiency, and again, Andrea Spiker is when we deal with open management for some of these insufficiencies as well. And so again, Andrea I don't think mentioned, she comes from Wisconsin, University of Wisconsin. So there are many causes of failed hip arthroscopy, and we're going to focus really on the salvageable causes. So things like poor patient selection, people with too much arthritis, or that might have extra-articular impingement. We're going to talk about some of these. That I think is all about patient selection up front, and so this is really not what this is about. So when I have patients that come to see me that have pain after having a hip arthroscopy, I go through kind of a checklist of different potential causes of this. And so the first would be, you know, is this a rehabilitation issue? Are they stiff? Are they generally stiff? Do they have adhesions? Are they weak? Do they have tendonitis? So being too aggressive potentially with the rehab for what their muscles are ready for. Was it the right diagnosis to begin with? Is their pain truly intra-articular? Was it truly intra-articular to begin with? Could it have been actually an iliopsoas or hip flexor type of issue, since that sits right on top of the joint anteriorly, and that's where the pain was really coming from? Could they be so-called hamstring dominant? And that puts more of a load on the iliopsoas, and we'll see people that might have had iliopsoas tendonitis got better, but it comes back because they were hamstring dominant. Or could this just have been referred pain to the joint? We know that the differential diagnosis of hip pain is very extensive. And then when it comes to the surgical technique, the bony resection, did they get, was it an under resection? Was it over resected? And how we would manage that. And then what about, do they potentially have instability? Did they have instability before they actually had their first hip arthroscopy, and that just wasn't addressed? Or were they made iatrogenically unstable, so by cutting the iliofemoral ligament or taking them from what might have been on the borderline to becoming unstable? Or do they have a soft tissue deficiency? And then other considerations include things like heterotopic ossification after hip scope. They have low AIIS, so they have subspine impingement. And could femoral aversion have been part of the problem? Because a lot of people don't assess femoral aversion preoperatively, and that could be oftentimes a cause. And then again, hip dysplasia, that may have been under-recognized. And so we're going to be spending a lot of the time, Shane will be talking about soft tissue deficiency with regard to the labrum, and Mark about soft tissue deficiency of the capsule, and things like femoral aversion and dysplasia will be talked about in greater detail by Dr. Spiker. So the first cause of when we talk about failed hip arthroscopy, and this was a paper that Mark Philippon published a long time ago and others have shown the same thing, that a lot of times patients that have failed hip arthroscopy have residual or untreated FAI. And so when you look at the different series, the numbers are somewhere between two-thirds and almost all of the patients had untreated FAI or residual FAI. And again, the original paper by Mark showed that 60% had untreated FAI and 32% had undertreated, if you will, FAI. Others have shown, again, similarly very high numbers of untreated or residual FAI as the cause of their revision. And so it's not just under-resection that's an issue, though. You can't have over-resection, and that can also cause problems in patients. What about changing indications for revision? Well, in my practice, I see an increasing number of individuals that come to see me who have failed hip arthroscopy that have hip instability. And a couple of years ago, Brian Kelly looked at their series at HSS of revision hip arthroscopies, and they found the same thing. They found that two-thirds of the patients did have untreated or residual FAI, but they also found that almost 15% had instability, not an insignificant number, and certainly more than the number three and four causes of revision hip arthroscopy. So starting off with incomplete rehab, well, you know, why would some people have incomplete rehab? Well, there are some physicians or surgeons that don't believe in formal physical therapy. Some patients just don't have the time or desire to go to physical therapy. Sometimes insurance companies don't provide adequate amounts of physical therapy. And then you might just have an inexperienced physical therapist that may not be used to dealing with non-arthritic hip problems, and post-operative patients that have hip preservation types of surgeries, they might be too aggressive or not aggressive enough. So they can get the tendonitis from being too aggressive, or if they're not aggressive enough, they'll end up being stiff. And so when you look at stiffness, it often comes from not moving after surgery or just prolonged bracing that would limit, and they could have generalized stiffness. But they can also have stiffness as it relates to adhesions, and the adhesions can be either in the peripheral compartment or they can be capsular labral adhesions. And so when you look at the normal anatomy of the hip, you can see that there's normally a cleft between the labrum and the capsule. The capsule, unlike the shoulder where the capsule inserts into the labrum, in the hip, the capsule inserts directly into the acetabulum, and the capsule and the labrum should move independently. And if there's adhesions, obviously you cannot do that. So the ways to manage that, and certainly ways to help avoid it, but when we see patients that are getting stiff post-operatively, I send them physical therapy for joint mobilization types of techniques, as well as traction techniques that are well accepted. But sometimes that doesn't work. Here you can see a patient that actually had been on crutches for almost eight weeks after their hip arthroscopy. She had a very stiff hip, and when we scoped her, you could see she had these big adhesion bands between the femoral neck and the anterior capsule in the peripheral compartment. But you can also see, as I said, the adhesions in the central compartment between the capsule and the labrum. So here you can see we just resected that big adhesion there to help get her range of motion. And here's a gentleman that you can see very clear adhesions between the labrum and the capsule that I'm probing on with my radio frequency device. And using the radio frequency device, you can see we can just go ahead and cut the adhesion so that they'll go ahead and move independently. And that helps reduce their pain and the pulling sensation they feel from these dense adhesions. They may have weakness. Mostly the issues are related to the gluteus medius and the iliopsoas, as well as working on the core. So the therapist generally should concentrate on that. You want to start slowly and gradually build. If they go too fast, they can get tendonitis. But you want to have them focus in these different groups. With regard to tendonitis, probably the three most common locations, and I don't see these nearly as much as I used to, but probably because I'm dealing with more experienced therapists that I had in the past, is that they could have iliopsoas tendonitis, which is very common, especially as you're going sometimes through the iliopsoas to access the joint. But also a lot of patients have iliopsoas tendonitis preoperatively. Adductor tendonitis or adductor-related pain, as well as piriformis-related pain. And for these things, for the treatment, you want to back down on the strengthening. You want to make sure they stretch those muscles to have them take non-steroidal anti-inflammatories, try modalities. And if that doesn't work, I think sometimes ultrasound-guided injections can help calm those down to allow for easier rehab. As far as the wrong diagnosis, well, did they have the right diagnosis to begin with? I've certainly seen patients that I had their hips scoped and they said their pain is exactly the same as it was. We give them an intra-articular injection, the pain didn't go away. And we said, you know what, probably wasn't the joint to begin with. And I've seen all sorts of different things that have mimicked hip pain, if you will. So we know that labral tears can occur in 70 to 80% of adults who have no hip pain. And so just because they have groin pain and they have an MRI that shows a labral tear does not mean that's the source of their pain. And as I said, probably some of the greatest mimickers are iliopsoas or tendonitis or hip flexor tendonitis. Again, the hamstring dominance issue, which I think strains the iliopsoas as well. And again, referred pain is not uncommon. I've seen people with so-called sports hernias that surgery got rid of that pain. So I like to use intra-articular injections to help confirm whether or not the pain is actually intra-articular or not when they have a failed hip scope. But we also do that in all patients preoperatively as well. So I think it bears probably some time to actually talk a little bit about the iliopsoas issues and the hamstring dominance, because I think we don't examine those quite as well as I think we could. And I credit Pierre Holmisch in Copenhagen for understanding how to better exam the iliopsoas. So with this, you can examine the iliopsoas below the inguinal ligament, which is where you'll feel the iliopsoas tendon, or above the inguinal ligament, that's where you're actually pushing more on the psoas muscle. And so what I do is I start the patient and have them hold the leg up in flexion, abduction, extension, rotation. The iliopsoas is on tension. I palpate the iliopsoas tendon. I go just medial to the iliopsoas tendon with the tips of my fingers. I have them straighten their leg out, and then I have them lift the leg up. And with that, you'll actually feel the iliopsoas hit against the tip of your fingers, and they'll tell you whether or not that reproduces their pain or not. You want to also assess seated hip flexion strength, because we know the iliopsoas is most active and isolated in flexion beyond 70 degrees. So we check their strength and see if that also reproduces their pain. And then we do tests for hamstring dominance. And by having the patient laying prone, I put my fingers on their glute and on their hamstring, and I have them lift their leg up. And you see which one fires first. Neil Ranawat likes to talk about this as being glute dominance, or glute inhibition, sorry, and I talk about hamstring dominance. It depends on which side you want to look at it from. But if they fire their hamstrings before their glute, that's not the right process, and that can lead to hip pain. And again, as far as, and it puts more stress on the iliopsoas, and again, what I like to do is have ultrasound-guided injections for the iliopsoas to see if that relieves the pain. I think fluoroscopic-guided injections, they aim oftentimes for the lesser trope. And the burst is not as well developed down there. It's kind of gone. And so it's not always an accurate shot. But if they do it with ultrasound guidance, they do it more towards the tendon, up in the peripheral compartment of the femoral neck region, they can oftentimes get it in the bursa reliably, and that will bathe the joint. Sorry, and this is just showing the hamstring dominance test. So again, preferred pain, as we talked about, the long differential diagnosis, articular, periarticular muscles, low back pain, GI, including hernias, GU. I've seen people that have had pain that was thought to be from the joint itself, and again, that ended up being a femoral hernia, which is a little bit less common type of hernia. Again, they got the surgery, and that took care of their hip pain. So I like to, again, make sure with an intraarticular injection, for me, my threshold is 50% relief of pain. If they get at least 50% relief of pain, then we can feel confident that the pain is coming from inside the joint. The problem I have is usually around this time of year when the MSK fellows at Stanford come and we have new MSK fellows trying to do the injections. Sometimes they don't work, or sometimes the patients say that it didn't help, and then you ask them, and they may have had 10 or 20 sticks before they got it into the joint, and I don't know that anything was going to help in that scenario. And I think these 3D collision software can be very helpful at looking at as to whether or not there's any residual impingement or subspinous impingement. So with these, they can move the hip around, and so you can see it three-dimensionally and then dynamically actually show the femoral head relative to the acetabulum and how that might be causing some residual impingement. So these can be very helpful in evaluating patients with failed hip arthroscopy. So here's an athlete that had FAI surgery, and you can see was still having pain, and you can see that there's some regrowth in this area that might be causing some of this further impingement. And so, again, as we said, it's not common to see regrowth except in younger kids with open physis. I tend to see that a little bit more than adults, but obviously then if they do have some regrowth or an untreated FAI, then going ahead and doing a revision FAI surgery will help get rid of that. On the other side, though, oversection can be a problem, and I think this one is a bit more difficult to manage arthroscopically. This was a gentleman that came to see me for pain preoperatively. He went elsewhere to get his surgery, and you can see when he came back, quite dysplastic. These were actually AP pelvis films that I'm just coning down, but you can see quite dysplastic. This is not readily manageable through the scope. And here you can see just a big oversection of the anterior femoral neck as well. What about instability? You can have people that are just preoperatively loose-jointed, and it may not, and the capsule, dealing with the capsule may not have been recognized as being a potential problem or risk for them. And then you can have those that have microtraumatic, your dancers that are constantly trying to get that external rotation, stretching the iliofemoral ligament. Again, we're seeing this as an increasing cause of failed FAI. Certainly we're better in our recognizing FAI now, but more experienced hip arthroscopists are also recognizing, I think, the instability and also managing how to manage the capsule. So early on, people were doing inter-portal capsulotomies, and we showed anatomically in a study that if you join your anterior and anterior lateral portals, you're cutting the iliofemoral ligament, which is obviously the strongest ligament in the body and can lead to anterior instability or micro-instability. And then some have gone on to do T-capsulotomies, and that can be also a problem. If you cut far enough down, you can cut the zona orbicularis, which will give you distraction instability as well. And so that does give you more visualization by doing a capsulotomy. And Shane Ngo has done some great biomechanic work that has shown that there's greater femoral head translation when you have a capsulotomy. And so the question is actually, once you repair it, though, does that heal or not? And that's another thing that we still have to study. But some people might have been susceptible but were stable when they had the surgery, and then by doing the surgery, it made them unstable by cutting the iliofemoral ligament and not repairing it. Again, those people might be ligamentously lax, have hypermobility, they might have some loss of labrum, because we've shown that labral tears in conjunction with the lax capsule increases the instability. And then again, could there be an iliofemoral ligament issue? Frequently people will have CAM lesions with some borderline dysplasia, and people not recognize that they had borderline dysplasia as well, and that might make the dysplasia a bigger component of what's going on. So it may not just be the lateral center edge angle. So what you're looking on an AP x-ray, they might have anterior insufficiency, or they might have excessive acetabular aversion that decreases the anterior wall, or they might have a high tonus angle, and people don't always measure those things, and so it might be unrecognized. And again, there might be a capsular labral defect. So here's this kind of classic case of this patient that came to me after having FAI surgery. This was their pre-op film before their FAI surgery. You can see they have kind of a large femoral head. They had an increased alpha angle, but they also have borderline dysplasia, and so that by just doing the FAI surgery and not managing the capsule, that led to the instability. We also see it with the people with microtraumatic, so your dancers, and then those with generalized laxity, and then you can also see here with an MR arthrogram, a postoperative case where there's leakage of the contrast from the joint itself. And so the way we manage these is by doing a capsular plication. So I do this laterally. Some people do it anteriorly where they shift the iliofemoral ligament. I do this in an area that is analogous to the rotator interval of the hip. So the blue is the iliofemoral ligament. The green is the ischiofemoral ligament. There's no real ligament in the lateral part of the capsule between 11 and 1, and so we take out a piece of the capsule there, and we just close that up, and that ends up tightening up the ligaments a little bit. So here's a case of a patient that had prior arthroscopy, continued to have pain, and you can see there's the femoral head. There's the labrum. There's the capsule. That's the iliopsoas, not the usual view of an iliopsoas. So this is a big capsular defect, and we went ahead and repaired the capsule back again to the acetabulum above the labrum, trying not to involve the labrum so that they can move independently. So as far as capsular defects, Mark will talk more about capsular defects. And again, as far as the labrum, if they've had a partial labrectomy or a prior repair or reconstruction, Shane will talk about the role of labral reconstruction. For me, I use these in a primary situation only in those patients that have dysplasia with an irreparable labrum, or we do it certainly in revision cases as well, and so that's just passing. I'd like to do segmental labral reconstruction. Heterotopic bone is rarely a source of pain. We do see it periodically, but it's rarely the source of pain. But here you can see a rather large HO that might block range of motion. And here you can see it on the CT scan. And these, I think, can be taken out fairly readily. I do it arthroscopically, and I think it can be done readily that way. Again, subspinous impingement and version issues, Dr. Spiker will be talking a little bit more about dealing with the version issues, but recognize that they exist. Publications suggest revision arthroscopy is not as good. So obviously you want to do it right the first time, but if they do fail, and we do see an increasing number of failed hip arthroscopies, you want to be able to identify the cause. You want to make sure, first and foremost, that the pain is intraarticular. You want to identify and treat the cause. Again, sometimes it's not an intraarticular source, and again, instability is being recognized more frequently as a cause. So hopefully we've alerted you a bit to that, as well as the iliopsoas issues. I think if it is an intraarticular source, a lot of times you can have the outcomes approach that of a primary. So thank you very much.

failed hip arthroscopy

persistent pain

rehabilitation issues

misdiagnosis

tendonitis