Hip
Failed Hip Arthroscopy
What is FAI?
FAI (Femoroacetabular Impingement) is a common hip joint disorder in young, active patients caused by a structural problem, specifically abnormal bone growth, that leads to irregular contact between the acetabulum and the femoral head. The hip is a ball and socket joint. The socket is the part of the hip bone called the acetabulum, and the head of the femur is the ball. Articular cartilage covers both the ball and the socket and functions to reduce friction for smooth joint movement. In a healthy hip, the ball of the femur fits perfectly into the acetabulum. However, in individuals with FAI, there may be irregularities in the shape of either the ball or the socket, or both. These irregularities cause hip joint impingement during activities like walking, running, or bending the hip, which can result in hip impingement symptoms such as groin pain and discomfort.
The location of the hip impingement can be described as either CAM impingement or Pincer impingement, or both. The CAM type is caused by the abnormal shape of the femoral head and neck, while the Pincer-type is caused an abnormal shape of the acetabulum. In some cases, both types can co-exist.
The friction and pressure caused by FAI can lead to further hip joint damage over time, including bone spurs, a labral tear, and hip osteoarthritis. Thus, early hip impingement diagnosis by a hip impingement specialist is crucial.
What is a labral tear?
The hip labrum is a ring of cartilage that surrounds the hip socket, providing stability to the joint. The hip labrum plays an important role in maintaining normal hip function. It functions to tighten the seal between the bones for joint stability, allows for a wide range of motion, and helps to maintain the alignment between the bones. A hip labral tear occurs when this cartilage is damaged or torn, often due to a hip injury, degeneration, or FAI. This tear can lead to a range of symptoms, including hip labrum pain (groin pain), clicking or catching sensations, and a decreased range of motion.
What is the hip capsule?
The hip capsule is a crucial anatomical structure that provides stability, protection, and lubrication to the hip joint, enabling smooth and controlled movement of the leg while also preventing excessive motion and potential injuries. The hip capsule, also known as the acetabular capsule, is a fibrous, ligamentous structure that surrounds and stabilizes the hip joint. It consists of strong connective tissue and ligaments that form a capsule-like structure around the ball-and-socket joint of the hip. The functions of the hip capsule include:
Joint Stability
The hip capsule plays a crucial role in maintaining the stability of the hip joint. It helps keep the head of the femur securely within the socket of the acetabulum. This stability is important for weight-bearing, movement, and activities such as walking, running, and jumping.
Lubrication and Nutrition
The synovial membrane lining the inside of the hip capsule produces synovial fluid. This fluid lubricates the joint, reducing friction between the articulating surfaces and ensuring smooth movement. It also provides essential nutrients to the cartilage within the joint, helping to maintain its health.
Joint Protection
The capsule acts as a protective barrier for the hip joint, helping to shield it from external forces and injuries.
Limiting Excessive Movement
While allowing for a wide range of motion, the hip capsule also limits excessive movement of the joint, preventing dislocations and maintaining joint integrity.
Proprioception
The ligaments within the hip capsule contain sensory receptors known as proprioceptors. These receptors provide feedback to the nervous system about the position and movement of the hip joint. This information helps with balance, coordination, and posture.
What causes a failed hip arthroscopy?
Re-injury to the hip labrum or hip capsule following hip arthroscopy can occur for a variety of reasons. Most commonly, patients may recall a trauma or injury in which the operative leg was forced into either an extreme degree of extension or external rotation. Additionally, failed hip arthroscopy can occur due to the presence of pre-existing risk factors such as hyper-laxity (Ehlers Danlos syndrome), untreated hip dysplasia, osteoarthritis, or a degenerative labrum.
What are the symptoms of a failed hip arthroscopy and hip labral repair?
Symptoms of a failed hip arthroscopy include:
- Intermittent deep groin pain or ache (most common)
- Pain at the outside of the hip joint
- Sharp stabbing pain when twisting, turning, or squatting, such as when getting in or out of a car or a chair.
- A dull ache from prolonged sitting or walking
- A sensation of catching, clicking, or locking in the hip joint during movement
- Instability of the hip joint
- Stiffness and reduced flexibility in the hip joint
- Limping
How is a failed hip arthroscopy diagnosed?
During your consultation with hip surgeon Dr. Bryan Penalosa, your medical and surgical history, FAI symptoms, and past injuries will be reviewed. It is highly recommended to bring all records from your previous FAI surgery, including the operative report, any surgical photos, and any subsequent imaging, to your consultation with Dr. Penalosa, as this information can be very helpful in the diagnostic process.
Physical Exam
He will conduct a physical examination checking range of motion including flexion, adduction, and rotation to diagnose your hip impingement. The hip impingement test will also be performed during your physical exam. This is a test in which Dr. Penalosa will ask you to bring your knee to your chest while he rotates the knee in toward the opposite shoulder (FADIR: flexion, adduction, and internal rotation). If the hip impingement test causes pain, you likely have a hip labral tear. A comprehensive physical exam is key to determine the cause of your hip pain.
Imaging
Diagnostic imaging is necessary to definitively diagnose FAI and a hip labral tear. X-rays will reveal abnormally shaped bones, and an MRI will reveal damage to the soft tissue, such as a re-tear of the labrum or an injury to the hip capsule. A CT scan may be necessary to further evaluate details about the shape of the bones, location of abnormal bone growth, and the rotation of the bones that may have contributed to the re-injury.
Hip Injection
An intra-articular hip injection can help confirm the diagnosis of a failed hip arthroscopy. This injection will be performed in the office at the time of your visit under ultrasound guidance. If the majority of your pain goes away, even temporarily, following the injection, then it confirms that the source of the pain is due to a possible re-tear of the labrum or capsular injury.
Failed Hip Arthroscopy Treatment Options
Can a failed hip arthroscopy be treated without surgery?
In cases with a mild to moderate re-injury to the labrum or capsule, a failed hip arthroscopy can be treated without surgery.
Non-operative treatment of a failed hip arthroscopy involves a change in activities to avoid movements that cause hip pain, including taking time off from activities that cause hip pain, using over-the-counter anti-inflammatory medications to reduce pain and inflammation, and physical therapy. Typically, symptoms will resolve within several weeks of conservative, non-surgical treatment. A steroid injection can also help relieve hip pain. If your hip pain is resolved with non-operative treatment and you can return to your desired level of activity, then no FAI revision surgery is needed.
What are the surgical options for FAI?
When nonsurgical FAI treatments do not relieve hip pain and imaging confirms re-injury to the hip labrum or hip capsule, then hip surgery is a reasonable option. FAI revision surgery can be performed in a minimally invasive procedure called hip arthroscopy. FAI revision surgery is usually an outpatient procedure, and you will go home the same day. During your FAI revision surgery, Dr. Bryan Penalosa will remove any remaining abnormal bone growth causing the hip impingement and repair any re-injury to the labrum or capsule. In some revision cases, a labral or capsular reconstruction may be indicated. Surgery typically lasts about 1–2 hours. Revision hip surgery is customized for each patient based on each patient’s unique hip anatomy, hip condition, and previous hip surgery.
Labrum Reconstruction
Hip labral reconstruction surgery is a procedure that replaces the damaged part of the labrum with a graft (typically a donor graft, otherwise known as an allograft) in order to regain stability and normal function of the hip joint. The major difference between labral repair and reconstruction is that repair consists of reattaching the torn labrum to the hip socket, whereas reconstruction involves replacing a segment or the entire native labrum. Labral reconstruction can be performed as a partial or full labrum reconstruction. A partial reconstruction preserves the healthy part of the labrum and replaces only the damaged segment. A full reconstruction involves replacing the entire native labrum with a graft. The decision to perform one over the other is based on the patient’s unique characteristics, past hip surgical history, and the quality of the labral tissue itself.
Labrum Augmentation
A labral augmentation surgery consists of using tissue from another part of the body (autograft) or a donor (allograft) and attaching it to the top of the native labrum to restore the suction seal. This is indicated in a subset of patients in which the labral tissue near the rim is healthy, but there is not enough of it to maintain the suction seal, leading to micro-instability of the hip and hip pain. Labral augmentation is a relatively new alternative to reconstruction that is used to restore the stability of the joint. It is thought that the blood supply of the native labrum helps the graft heal postoperatively.
Capsular Reconstruction
Capsular reconstruction surgery is a procedure that replaces the damaged capsule with a graft from another part of the body (autograft) or a donor (allograft). The goal of this procedure is to restore stability and the biomechanical properties of the hip joint. The difference between capsular repair and reconstruction is that repair consists of cleaning the frayed capsular tissue and reattaching the torn edges together, whereas reconstruction involves removing the deficient capsule segment and replacing it with a graft. Capsular reconstruction is indicated for patients who have symptoms of hip instability, weakness, or pain due to a deficient joint capsule, have failed conservative management, and who are not candidates for repair. Most commonly, patients will present with micro-instability after previous arthroscopic hip surgery when the capsule was not restored. During hip capsular reconstruction surgery, the defect in the hip capsule is measured and an appropriately sized graft is prepared. The new graft is laid over the defect and attached to the rim of the hip socket and the healthy segment of the native capsule, therefore restoring the dynamic stability of the hip joint.
Recovering from FAI Revision Surgery
How long is the recovery after FAI revision surgery?
The recovery time after FAI revision surgery can vary depending on several factors, including the extent of the surgery, individual patient characteristics, and the level of activity that the patient is striving to return to. In general, most patients can recover full, unrestricted activity in 4-6 months following FAI revision surgery so long as they complete a good physical therapy program.
Here’s a general overview of what to expect after FAI surgery:
Initial Recovery Phase (0-6 weeks):
The immediate post-operative period following FAI revision surgery involves rest and protection of the surgical site. Patients will be non-weight bearing for 4 weeks following revision hip surgery, typically using crutches for a total of 4-6 weeks. A hip brace will be worn for 4-6 weeks following surgery. Physical therapy and the use of a continuous passive motion machine will begin on post-operative day 1 to improve range of motion and reduce swelling. Pain and discomfort are common during this phase, but medications are prescribed to help manage it.
Intermediate Recovery Phase (6-12 weeks):
During this time, physical therapy intensifies to improve strength, stability, and mobility. Return to light, low-impact activities may be allowed under the guidance of Dr. Bryan Penalosa and his team, as well as your physical therapist. Patients should still avoid high-impact activities or activities that involve excessive hip stress.
Advanced Recovery Phase (3-6 months):
As strength and range of motion improve, patients can start transitioning to more demanding activities. Physical therapy continues to focus on functional movement and sport-specific exercises. Return to full activities, including sports, typically occurs around 6 months following FAI surgery after Dr. Bryan Penalosa has formally evaluated and cleared the patient to do so.
Long-Term Recovery (6 months to 1 year and beyond):
Complete recovery may take up to a year or more. Patients should continue with maintenance exercises to ensure long-term joint health.
Long-Term Effects of Untreated Failed Hip Arthroscopy
What are the long-term effects of untreated failed hip arthroscopy? Can an untreated failed hip arthroscopy lead to hip arthritis?
Hip preservation refers to the use of procedures to protect and maintain the labrum (the cartilage that lines the hip bone to deepen the hip socket) to prolong the natural lifespan of the hip, prevent arthritis of the joint, and to avoid or delay hip replacement surgery. FAI predisposes to premature joint degeneration.
Untreated FAI and failed hip arthroscopy can indeed lead to long-term complications, and one of the potential consequences is the development of hip arthritis. Here are some of the long-term effects of untreated FAI and failed hip arthroscopy:
Progressive Hip Joint Damage:
FAI involves abnormal bone growth in the hip joint, causing friction and hip impingement during movement. Over time, this repetitive mechanical stress can lead to the gradual wear and tear of the hip joint tissues, including the cartilage lining the joint.
Cartilage Damage:
As FAI persists, the friction within the hip joint can damage the articular cartilage, which provides a smooth surface for joint movement. This cartilage damage can result in hip pain, joint stiffness, and decreased mobility.
Hip Arthritis:
Perhaps one of the most concerning long-term effects of untreated FAI is the development of hip osteoarthritis. The gradual wear and tear on the joint’s cartilage and other structures can eventually lead to arthritis, characterized by pain, inflammation, joint deformity, and reduced mobility.
Secondary Hip Conditions:
Untreated FAI can increase the risk of developing secondary hip conditions, such as tendinitis, hip bursitis, and muscle strains, due to altered hip mechanics and abnormal loading of the joint.
It’s important to note that not everyone who suffers a failed hip arthroscopy and persistent FAI will progress to hip arthritis or develop long-term effects of FAI, and the rate of progression can vary widely among individuals. However, addressing a failed hip arthroscopy early through conservative treatments or surgical intervention can help reduce the risk of these long-term complications and improve hip joint function and overall quality of life.
If you suspect you have failed a previous hip arthroscopy or are experiencing hip pain, contact Dr. Bryan Penalosa today to schedule a hip evaluation. Dr. Bryan Penalosa is a sports medicine orthopedic hip surgeon in Chicago, Illinois who specializes in the treatment of hip injuries. He is internationally recognized for his contributions to the field of sports medicine and is a pioneer in novel therapies, including FAI, hip labral tear, revision hip arthroscopy, and hip preservation. Dr. Penalosa’s focus is on customized and personalized care to meet the needs of each of his patients. He uses minimally invasive arthroscopic procedures to preserve the natural joint and reduce recovery time to accelerate his patients’ return to the activities they love.