Name: Joint Instability After Hip Arthroscopy
Uploaded: 2016-07-15T00:00:00Z
Channel: Arthrex

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VPT1-00675-EN | A | Joint Instability After Hip Arthroscopy

Asheesh Bedi

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Joint Instability After Hip Arthroscopy

I'm going to finish this out, for better or worse, with our our last talk on joint instability after hip arthroscopy. And I think we can keep it fairly straightforward and simple as some some take home points as you get to sort of the most difficult things to manage. I think the take home point for me is what's the reality of joint instability after hip arthroscopy? It's one of our most feared complications and that we would do a scope, do these extensive capsulotomy and the hip will somehow dislocate or recurrently dislocate after surgery. But the reality is that it's feared, but it's actually an exceedingly uncommon event with well indicated surgery and what's otherwise a reasonably congruent joint that's constrained well by osseous anatomy. This has been case reported. This is a case actually from Omar Madan that talked about a catastrophic dislocation event, iatrogenic instability after a scope. But we'll talk about this here in just a moment. If you look at this film, I think the take home point here is, is this really necessarily A straightforward hip to begin with. I think we appreciate even on the measurements that are on their their paper here, a reduced center edge angle and increased acetabular index or tonus angle. And so how many of these are in fact cases where there is some element of underlying dysplasia or instability to begin with. So I think iatrogenic instability, while it can be this rare and feared case, is really more likely a scope that that is occurred on a case that already has some existing dysplasia, excessive femoral anteversion, or both. Or it's a case that we're scoping after a traumatic instability event a posterior hip fracture, dislocation or subluxation event where there's already injury to the ligamentum teres, to the capsule, to the soft tissues, and all of those things are contributing to an environment where there's a challenge. Why I think this is becoming more and more important is as we're expanding our indications for hip scopes to take on these, quote unquote, borderline cases or cases where there's some instability or micro instability, the chance exists that as we take things out of balance by dividing or excising capsule or compromising soft tissue. Maybe now we're seeing more of these kind of cases. I showed this picture earlier because I think it speaks to that. This is that kind of case where if you looked at the inherent anatomy initially, you'd say, not so bad. There's a slightly increased acetabular index or tönnis angle, not bad lateral coverage. But again, as we try to take this type of case onto the scope, if we excise all the capsule and excise the labrum, then are we left with the image on the right side of the screen? This I can move through quickly because it was already covered very nicely by Carl before and Mike Yusuf and others. But remember, what are we really worried about with instability? It's compromising this soft tissue envelope of all the different ligaments that surround the hip, the iliofemoral ligament or y ligament of Bigelow, the femoral and ischiofemoral ligament, the one that we worry about the most is this one. It's the iliofemoral ligament. It's the two limbed ligament that looks like this inverted Y. And why is that important? Because now that we tend to more frequently perform an inter portal capsulotomy, we cut right across those fibers there. This is looking at looking at that from the front between the iliac capsularis and gluteus medius. And so it may not be just the capsulotomy that can compromise it. It may be that inner portal cut that compromises it again. Do I think that needs to be repaired every time? Absolutely not. But on the other hand, it's just a consideration because in these cases where the capsule becomes more relevant, we probably have to pay attention to it more carefully. So how do you characterize these forms of instability that can occur? I think they fall kind of in one of these four categories. The traumatic ones are the ones that all of us are used to as orthopedists. The hip is put in a vulnerable position and a high energy mechanism dislocates it. There's the atraumatic mechanisms, which really reflect dysplasia or instability that preceded or predated our presence there with an arthroscopy. There's this newer concept which I'll show here in a minute of Fe induced instability. And then finally this last category, which is this rare case where we have created something through a capsule ectomy or capsulotomy that renders it unstable. This is the so-called Fe induced instability. Again. Brian Kelly and Tom bird have published on this. This is this case where perhaps the the cam deformity in the front of the joint leads to a levering effect and can lever the joint out the back. And these kind of traumatic mechanisms have been seen more and more. We've seen them in football, even with non-contact events where the levering effect in extremes of flexion, adduction and internal rotation lever the hip out the back, in this case, treating the the deformity in the front of the joint and correcting the fay can actually be paradoxically better for instability that's related to it. I think. What are our tips and pearls when we're taking on these cases? This is actually right from Amir's paper. I'm not going to belabor all this, but it basically says everything that we've just talked about. Identify the patients that are at risk, the ones with high Beighton criteria, you know, positive thumb to forearm testing, elbow hyperextension, recurvatum a reduced center edge angle. Find things that make you concerned about either bony deformity that is consistent with a dysplastic variant, or soft tissue pathology that's consistent with hyper laxity. If you're going to see those patients and take them on with arthroscopy, be aware intraoperatively to manage the capsule responsibly. Minimize your traction time as that can stretch and deform the capsule. And again, I have a post-operative protocol that's maybe a little more protective of the soft tissue healing. What are the advantages and disadvantages. I'm not going to belabor this. But again we talked about leaving the capsule open. Maybe in some cases where you can rely on the bony congruency, it can make patients stiff. In other patients it's important to to restore stability. It's technically more demanding to repair the capsule. But with devices that Arthrex are coming up with and our ability to handle the soft tissues more responsibly, I think more and more of us are able to close the capsule at the end of the case in kind of a reliable fashion. Again, this is sort of pointing at that. Why? Because as we extend our capsulotomy to an inner portal cut and t cut, it improves our visualization, but it can come at the price of stability. And so this is again just a summary slide. This came right out of that paper. And it's a good one to look at to remind yourself. For each of these manipulations that we do, cutting the capsule or retracting the capsule, closing the capsule, what are the risks and benefits? And this is a paper recently published by Schein and the rush Group showing that in some of these revision cases, we often don't get a second look. But this is a second look example where you can appreciate this capsule or window here that exists between the labrum and the femoral head, where the switching stick has been passed. And this was a patient that was complaining of some instability in provocative positions of extension and external rotation, which makes sense here with this anterior capsular capsule or deficient window. Again, other studies have started to publish this more and more. This is another one from the Duke group, from Chad Mather and Shane and others that again show this capsular window and defect. And you can see on this, Mr. ArthroRome, after a prior arthroscopy, really no capsule visualized in the front of the joint with sort of a floating psoas tendon. So primary capsular closure at the first surgery may prevent these challenging operations now to deal with. Unless you have Mr.. Who can sew in an ArthroFLEX patch for you without the bezoar. This is kind of the revision hip arthroscopy group here. You know, when we learn from Marc Philippon and others who are these patients that are at risk? 35% of the patients, at least in his series in revision surgery, had some element of addressed instability. So again, I think this is probably there more often sees us than we see it. And it speaks to the fact that our capsular management strategies have have expanded, but but probably pushes our need to repair them. This is Ben's series as well. That shows the same thing. This micro instability group, these aren't gross dislocations, but these are nonetheless patients that are complaining of subjective instability. And it reflects that. Again, different techniques to repair it. Misty showed one. This is Omer demonstrating an open anterior capsule reconstruction for these cases where it's not necessarily in need of a Pao or a rotational osteotomy, the bony anatomy looks okay, but there's a completely deficient wide ligament or iliofemoral ligament here. He's described a two tailed approach to retention that bringing it to that anterior antero-superolateral margin that Misty described, and bringing the capsule down all the way to the Intertrochanteric line. The key here is not just that you repair the capsule, but that you tension the capsule appropriately. If you do this arthroscopically, one of the challenges you'll find is you're typically performing your peripheral compartment work in flexion to make room there. Oftentimes you'll tension the graft inflection. And as soon as the patient extends the hip you can lose or have a disruption of your repair. So it's important although challenging, to tension these graphs in relative extension. So you don't have a failure in the PACU. Again this is showing that open reconstruction. This is Amir's approach with an Achilles allograft. I think it matters less whether you do it open or arthroscopic, but more importantly that in these rare and complicated cases that you recognize it and treat it. I'll summarize here. Finishing up, I think, by what the real take home message from this should be is not that this is common, but that it's more common as we take on this borderline hip. What can be done? What should be done? What are the outcomes for and against arthroscopy? And so I'll quickly point out that we don't have a lot of evidence, and we don't even know what a borderline dysplastic is. And that's part of the problem. Instead, I'm going to summarize by saying not necessarily what the borderline is, but I think what we should not scope in 2016. So if you see a hip like this picture here where the femoral head is already lateralized, where if you see that it's extruded or there's a break in shenton's line, these are cases that already need a acetabular osteotomy or bony procedure. No arthroscopy is going to help this. It's likely going to hurt it by further destabilizing the hip. The only role for arthroscopy here would be in conjunction with a consideration for open correction, if the lateral center edge is less than 20 degrees, if there's excessive version, if there's excessive coxa valga in combination, or a high tonus angle more than 10 or 15 degrees, these should all be on your list of cases that probably should not be approached in isolation with arthroscopy, because they'll be met with an unstable hip that then necessitates a second operation.

Joint Instability After Hip Arthroscopy

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