Approach to the Patient with Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement

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Orthopaedics Articles Orthopaedics / Bone and Joint Center

7-1-2020

Approach to the Patient With Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement

Eric C. Makhni

Prem N. Ramkumar

Gregory Cvetanovich

Shane J. Nho

Follow this and additional works at: https://scholarlycommons.henryford.com/orthopaedics_articles Review Article Approach to the Patient With Failed Hip Arthroscopy for Labral Tears and Femoroacetabular Impingement

Abstract Eric C. Makhni, MD, MBA There has been an exponential increase in the diagnosis and Prem N. Ramkumar, MD, MBA treatment of patients with femoroacetabular impingement, leading to a rise in the number of hip arthroscopies done annually. Despite reliable Gregory Cvetanovich, MD pain relief and functional improvements after hip arthroscopy in Shane J. Nho, MD, MS properly indicated patients, and due to these increased numbers, there is a growing number of patients who have persistent pain after surgery. The etiology of these continued symptoms is multifactorial, and clinicians must have a fundamental understanding of these causes to properly diagnose and manage these patients. Factors contributing to failure after surgery include those related to the patient, the surgeon, and the postoperative physical therapy. This review highlights common causes of failure, including those related to residual bony deformity as well as capsular deficiency, and provides a framework for diagnosis and treatment of these patients.

ip arthroscopy is a rapidly evolv- after hip arthroscopy. Both successful ing field, with several recent im- diagnosis and management of these From the Henry Ford Health System, H Detroit, MI (Dr. Makhni), the Cleveland provements in both diagnostic and patients can be extremely challenging. Clinic Foundation, Cleveland, OH surgical capabilities. The number of hip Therefore, the goal of this review is to (Dr. Ramkumar), the Ohio State arthroscopies done annually has also provide orthopaedic surgeons with a University, Columbus, OH 1 (Dr. Cvetanovich), and the Rush steadily increased. Indications for hip comprehensive approach for the eti- University Medical Center, Chicago, arthroscopy have expanded to include ology, evaluation, and management IL (Dr. Nho). multiple different conditions, such as of patients with a failed outcome after Dr. Makhni or an immediate family femoroacetabular impingement (FAI), hip arthroscopy. member serves as a paid consultant cartilage preservation, labral fixation to Smith and Nephew. Dr. Nho or an and reconstruction, iliopsoas release, immediate family member has Etiology received royalties from Ossur, serves synovectomy and loose body removal as a paid consultant to Ossur and for synovial chondromatosis, and many We simplify the etiology of failure after Stryker, and has received research or others. institutional support from Arthrex, previous hip arthroscopy into patient Unfortunately, and corresponding Allosource, Athletico, DJ selection errors, patient-related fac- with the increase in number of hip Orthopaedics, Linvatec, Miomed, tors, and technical issues. Smith and Nephew, and Stryker. arthroscopies done, there has been a J Am Acad Orthop Surg 2020;28: similar increase in complications and 538-545 persistent pain after hip arthroscopy. Patient Selection Errors DOI: 10.5435/JAAOS-D-16-00928 These unfavorable outcomes include First and foremost, the patient must be those related to patient factors, sur- properly indicated for hip arthroscopy Copyright 2020 by the American Academy of Orthopaedic Surgeons. geon (or technical) factors, and others and related procedures. Therefore, if a that contribute to inferior outcomes patient is incorrectly diagnosed with

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Eric C. Makhni, MD, MBA, et al hip impingement, when his/her pain gery.7 Recent evidence has further pain and instability.21-23 Avoidance of and symptoms are likely due to a non- indicated a lack of reliable improve- activities that may cause flexor ten- hip etiology, that patient will be ment in patients with pre-existing dinitis postoperatively, particularly in unlikely to experience improvement arthritis (Tonnis grade 2 and 3) after the early postoperative period, may postoperatively. Commonly missed hip arthroscopy12;therefore,preoper- limit occurrence of anterior groin pain etiologies of hip pain may include ative radiographs should be studied to in these patients.24 It is important to conditions of the lumbar spine or low determine whether the patient met this note, however, that there is an overall back, groin, or extra-articular struc- classification.2-4,14 Older age at time of lack of high-quality evidence guiding tures of the hip joint. Similarly, if the hip arthroscopy may be associated clinicians regarding optimal rehabili- patient’s hip pain is due to underlying with higher failure rate and infe- tation guidelines after hip arthros- osteoarthritis, the results after hip rior outcome.4,11,14 Conversely, pa- copy.25,26 Although some pilot data arthroscopy may be less reliable.2-4 tients with evidence of generalized indicate a possible benefit to structured Therefore, comprehensive radiograph laxity without obvious bony deformity postoperative physical therapy,25,27,28 series must be obtained preopera- have also been shown to have inferior there is an overall paucity of high-level tively to rule out focal areas of outcomes after hip arthroscopy if clinical trials on this subject. arthritis that were otherwise not meticulous capsular management is Certainly, repeat trauma to the hip apparent on traditional AP and lat- not done.15 Untreated sports hernia is in the postoperative recovery process eral imaging sequences. Surgeons an additional pathology that should could lead to reinjury to the capsule must also meticulously assess for be considered and frequently coexists or labral structures. symptoms of dysplasia or other with FAI.16 deformity preoperatively as well.5,6 This may include excess femoral Technical Issues anteversion, global acetabular ret- Patient-related Factors As with any surgery, there are numer- roversion, as well as acetabular un- Patient factors play a role in success of ous procedure-related factors that may dercoverage (both lateral and anterior). hip arthroscopy. Patient preoperative contribute to failed outcomes after hip Multiple studies have demonstrated function, goals, and expectations are arthroscopy. These factors may be inferior outcomes in patients undergo- critical.17 In preoperative counseling, categorized into inadequate addressal ing hip arthroscopy with preoperative patients should be aware that litera- of bony and soft tissues, iatrogenic evidence of anterior acetabular under- ture suggests inferior results for older nchondrolabral injury, and nerve coverage.5-8 A proportion of these pa- patients, those with preexisting oste- injuries. tients will have notable and satisfactory oarthritic changes, worker’s compen- Optimal results after hip arthros- improvement in symptoms after this sation status, and those with elevated copy occur when all the bony and soft- rehabilitation and will no longer be body mass index.12,18,19 Patients with tissue structures are adequately ad- symptomatic. In addition, there may be these risk factors who are otherwise dressed. The main bony procedures consideration for selective injection good candidates for hip arthroscopy during hip arthroscopy are resec- postoperatively to better identify sites generally still experience high rates tion of the pincer deformity and os- of pain (eg, trochanteric versus intra- of notable improvements after hip teochondroplasty of the femoral articular). Unfortunately, there is a arthroscopy, but results may be less CAM deformity. Overcorrection or paucity of literature regarding the effi- robust than in patients without such undercorrection of either of these de- cacy and appropriate timing of these risk factors. formities may lead to inferior out- injections. Patients who are noncompliant with comes. Undiagnosed and untreated To select the ideal patient for index postoperative physical therapy regi- extraarticular impingement including hip arthroscopy requires understand- men or postoperative precautions may subspine or ischiofemoral impinge- ing of the consensus indications for hip experience pain in the early postoper- ment can also be a cause of poor out- arthroscopy as follows: correlation of ative periods, such as due to flexor comes.29 Avoiding over-resection has preoperative history and imaging indi- tendinitis or soft-tissue irritation in the become a central axiom in successful cating FAI, body mass index ,35,9,10 thigh. This could also involve stiffness hip arthroscopy management. Recent age under 45,11 joint space greater due to adhesions, particularly if early research has indicated that excessive than or equal to 2 to 4 mm on motion is not done.20 Excessive early resection of the pincer deformity may plain radiograph radiographs,12,13 and motion or failure to comply with lead to iatrogenic instability postop- absence of acetabular dysplasia or precautions could lead to failure of eratively.30,31 Therefore, when ad- excessive femoral retrotorsion requir- thelabralrepairorcapsularrepairto dressing the pincer deformity, it is ing open (concomitant or staged) sur- heal, potentially leading to persistent important to contour the deformity

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Figure 1

A 15-year-old female patient with persistent left hip pain after left hip arthroscopy including labral repair, iliopsoas lengthening, and femoral osteochondroplasty. The patient had initial pain relief after surgery for 2 to 3 months but then developed increasing pain with activity, as well as painful “popping” of the hip. Physical examination was notable for largely preserved range of motion along with numerous positive provocative examination findings, such as flexion-adduction- internal rotation, flexion-abduction-external rotation, hyperflexion, and instability signs. Initial postoperative imaging indicated persistence of lateral and anterior CAM deformity (A), and postoperative MRI arthrogram indicated capsular deficiency with extravasation of contrast agent (B). The patient was taken to operating room for revision hip arthroscopy for management of persistent CAM deformity and capsular deficiency. Diagnostic arthroscopy revealed notable iatrogenic chondral damage from initial arthroscopy (C), as well as unrepaired large interportal capsulotomy with some adhesions across the capsular free ends (D). A persistent CAM deformity was also noted (E). A revision osteochondroplasty and capsular plication were done (F) with anatomic capsular repair (G). The patient had relief of pain and instability symptoms after revision hip arthroscopy. Images courtesy of Dr. Shane Nho. without overly aggressive resection. Because of the confined nature of ity.37,38 Labral reconstruction may However, more attention has been the hip joint, there may be iatrogenic be required in these patients, which placed on the role of the CAM injury to the articular surfaces on can be done in a single or two-staged deformity. Because of its role in arthroscope and instrument entry fashion.39 propagating chondral delamination and manipulation.35 Therefore, care One increasingly recognized cause during hip impingement, the surgeon must be taken to ensure that ade- of hip pain postoperatively is capsu- must ensure that all bony areas of quate space is created during hip lar deficiency.21-23 In one recent impingement are adequately decom- distraction to allow for seamless study, patients who had not had re- pressed during surgery. Under- insertion and removal of arthro- approximation of the capsulotomy resection of the CAM has been scopic instruments. In addition to with poor outcomes experienced implicated as a leading cause for articular surface preservation, the notable improvement in symptoms persistent pain and symptoms after surgeon must also be cognizant of after revision surgery with capsular hip arthroscopy (Figure 1).7,29,32-34 proper labral preservation.36 In pa- plication.23 Patients with unclosed Therefore, it is our practice to do the tients with underlying dysplasia, the capsulotomies have higher risks of osteochondroplasty using both a labrum is hypertrophied and over- postoperative instability and pain dynamic and fluoroscopic examina- resection of the labrum may lead to that is different in nature and tion, thereby ensuring proper remo- iatrogenic hip instability. Similarly, severity than preoperative symp- val of the deformity. Similarly, overly patients with previous labral toms.15,40 There may even be prop- aggressive resection of the defect may débridement may experience loss of agation of cartilage disease due to lead to postoperative hip instability the “suction seal” and therefore the iatrogenic instability that may and should be avoided.31 subjective or objective hip instabil- lead to early degenerative changes.

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Figure 2 shows the images of a 52- ment, measuring an average of ure after arthroscopy in these pa- year-old woman with pain after hip 15 mm from the anterior portal on a tients.7,29,32,33 These patients arthroscopy and labral repair who cadaveric study by Robertson and typically demonstrate clear evidence underwent a subsequent revision hip Kelly.42 In addition, Robertson et al of FAI and bony impingement pre- arthroscopy because of worsening found that the midanterior portal operatively but have incomplete pain pain. No capsular repair was done at was an average of 19.2 m from the relief after surgery. Moreover, pa- index surgery. On revision arthros- ascending branch of the lateral cir- tients will state that the character of copy, which was less than six months cumflex femoral artery, but that no their pain is similar to those who after the index procedure, the patient other neurovascular structures were were present preoperatively. Plain demonstrated gross laxity when at- within 2 cm of a series of 11 hip radiographs may additionally reveal tempting to apply manual traction. arthroscopy portals.42 For creation persistence of bony deformity post- Arthroscopic findings included large, of anterior portals, it is important to operatively that may further indicate open interportal capsulotomy with stay lateral to a line drawn directly that there was under-resection of the rapid progression of degenerative down from the anterior superior CAM or pincer deformity. Literature findings of the labrum and femoral iliac spine to minimize damage to suggests that patients with acetabu- head articular cartilage. The patient the neurovascular bundle. The most lar dysplasia may have inferior out- was treated with side-to-side repair commonly injured nerve is the lat- comes after hip arthroscopy,5-8 of the capsulotomy. In patients who eral femoral cutaneous nerve, which although several authors have reported have instability after aggressive may result in numbness and par- successful outcomes of hip arthros- capsulectomy, a capsular recon- esthesias to the lateral aspect of the copy in the setting of borderline struction may be required.22 thigh. Most nerve injuries are tem- dysplasia.43-45 Another concern is development of porary and resolve within 3 to Recent evidence has also shown nerve injury in patients undergoing 6 months.35 that capsular deficiency may be an hip arthroscopy, due to both hip-post increasingly common cause for pain traction as well as portal place- after hip arthroscopy.21-23 Many of Diagnostic Evaluation of ment.35 Some authors have cited a these patients underwent surgery traction time of 2 hours as the risk Pain and Disability After with techniques that did not factor for neurapraxia due to trac- Previous Hip Arthroscopy emphasize capsular closure and tion as well as compression by the instead either had capsulectomies or perineal post, although Telleria et al41 History capsulotomies that were not closed found traction weight was a more The initial evaluation of a patient during surgery. It is our experience important factor for neurapraxia than with persistent or worsening symp- that some patients may actually traction time in a study monitoring toms after hip arthroscopy is that of have a period of symptom improve- somatosensory-evoked and motor- any new patient encounter. A thor- ment after surgery, as scar tissue and evoked potentials in hip arthroscopy. ough history will often provide the adhesions may serve to stabilize the The incidence of neurapraxia has been clinician with a focused differential hip joint during initial recovery. Pa- reported to be 1.4% for hip arthros- that will guide subsequent diagnostic tients will often then complain of a copy, with 99% of these being tem- tests and imaging. Critical compo- sudden inciting event that causes porary neurapraxia and only case nents of the history include deter- their pain to increase and result in reports of permanent nerve damage.35 mining the chief report. This may pain that was worse than it was The pudendal nerve is most commonly include similar pain and symptoms before surgery. This may be due to a affected (40%), followed by lateral that were present before surgery or lysis of the interval scar and adhesion femoral cutaneous nerve (21%), sciatic those that are different or worse than formation across the capsulotomy (17%), common peroneal (17%), and preoperative symptoms. site with resultant instability of the femoral (5%).35 Therefore, it is As FAI and associated labral tears hip. Therefore, review of the surgical important to minimize traction time are the leading diagnoses in patients note along with correlation of his- and traction weight when doing cen- undergoing hip arthroscopy,35 the tory may aid in establishing the tral compartment procedures. surgeon must also be aware of the diagnosis. Nerve injury may also result from most frequent reasons for failure portal creation and placement. The postoperatively. Traditionally, inad- lateral femoral cutaneous nerve is equate femoral osteochondroplasty Physical Examination considered the most at risk nerve resulting in residual FAI has been Along with a comprehensive history, a during hip arthroscopy portal place- cited as a leading cause of fail- comprehensive physical examination

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Figure 2

A 52-year-old woman with persistent pain and instability 5 months after two previous hip arthroscopies (for diagnosis of FAI and then subsequently for “labral retear”) over a 3-month period. On presentation to the principle author, the patient reported subjective instability of the hip that was not present before surgery. The examination was notable for decreased recoil on log roll examination, with the right hip persistently lax in external rotation (A), as well as a positive anterior drawer. Preoperative x-rays revealed normal bony alignment and preserved joint space of the hip, and previous arthroscopic photographs demonstrated labral repair with intact articular cartilage and labrum. However, on re-revision hip scope by the principle author, which occurred only five months after previous arthroscopy, there was obvious evidence of an unrepaired interportal capsulotomy (B)with markedly progressed degenerative changes, including notable tearing of the acetabular labrum (C) as well as chondral changes on the femoral head (D), presumably due to the underlying hip instability. A side-to-side repair of the previous capsulotomy was done (E) with ultimate plication of the defect (F). (G) Demonstrates representative labral reconstruction with allograft tissue in patients with labral deficiency found at time of revision surgery. Images courtesy of Dr. Eric Makhni and Dr. Shane Nho. will further aid in the evaluation of as well as loss of recoil in a log roll we obtain multiple plain radio- the patient. The examination con- test, will indicate possible instability graphs to examine the bony anat- sists of an assessment of stance and of the hip. Many patients may have omy. These consist of AP pelvis, gait, followed by a supine evaluation pain with resisted hip flexion, which false profile, and Dunn lateral of range of motion and strength. may indicate presence of hip flexor views. These images will demon- Provocative maneuvers, including tendinitis. strate any over-resection or under- flexion-adduction-internal rotation resection of the bony abnormality and flexion-abduction-external ro- that may have occurred during tation, can indicate presence of Radiographic Evaluation surgery. Joint space should be as- impingement both anteriorly and Finally, appropriate imaging will sessed. Heterotopic bone can cause posteriorly. In addition, a positive help confirm the differential diag- symptoms after hip arthroscopy drawer or apprehension maneuver, nosis. For all patients with hip pain, and can be identified on plain

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Table 1 Examples of Common Presentations After Previous Hip Arthroscopy Examination/Imaging Report Findings Diagnosis Management

“Same pain as before Preserved range of motion, Inadequate bony resection Revision hip arthroscopy with surgery” positive impingement on index surgery comprehensive resection of examination findings pincer and CAM deformities (FADIR), bony films demonstrating persistent CAM and/or pincer deformity “Same pain as before Limited range of motion Hip osteoarthritis Nonsurgical treatment surgery” (similar to preoperative), consisting of weight loss, evidence of decreased joint activity modification, anti- space ,2-4 mm that is seen inflammatory medication, on preoperative and and/or injection treatment postoperative films13 until candidate for hip resurfacing or total hip arthroplasty “Same pain as before Physical examination without Incorrect surgical Requires identification of the surgery” focal findings of hip indication underlying extra-articular impingement; normal plain pathology films Progressive worsening of Limitation in range of motion Postoperative osteoarthritis Same treatment for patient pain and/or stiffness not present in preoperative (either iatrogenic or with osteoarthritis as above examination; progression of idiopathic) osteoarthritis compared with preoperative Anterior groin/thigh burning Pain with resisted hip flexion, Postoperative flexor Restriction of activities and associated with increase tenderness to palpation over tendinitis weight-bearing, anti- in activity postoperatively flexor tendons inflammatory medications, (and not similar in nature and gradual return to to preoperative symptoms) activities when asymptomatic Subjective instability or Examination findings of 1 Postoperative instability Revision hip arthroscopy for feeling of “looseness” anterior drawer, decreased capsular plication or recoil on log roll; imaging of reconstruction. If instability MR arthrography indicating result of over-resection of capsular defect; pincer or CAM deformity, fluoroscopic examination may not be amenable to under anesthesia indicating arthroscopic revision. decreased resistance to hip distraction Hip pain without Examination may be normal. — Consider repeat work-up for clear pattern Imaging may be useful in causes of intra-articular detecting presence of versus extra-articular adhesions or iatrogrenic etiology, along with guided osteochondral injury anesthetic injections

FADIR = flexion-adduction-internal rotation radiographs.46 Advanced imaging defect with extravasation of contrast may be ordered as indicated. CT with material.47 MRI also allows for Management of Pain and 3D reconstructions is the study of evaluation of the labrum and carti- Disability After Previous choice to evaluate residual FAI and is lage as well for evidence of chondral Hip Arthroscopy useful for preoperative planning. In defects, labral tears, and possible the setting of possible capsular defi- labral deficiency. The surgeon must To summarize the above findings ciency, an MRI arthrogram can be also review any available surgical and recommendations, a stepwise helpful in delineating the capsular images as well. algorithm is provided below. The

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Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited. Approach to the Patient With Failed Hip Arthroscopy clinician should focus on whether comparative matched-group Analysis. J the symptoms are similar to those References Bone Joint Surg Am 2016;98:797-804. preoperatively, as well as pertinent 12. Chandrasekaran S, Darwish N, Gui C, References printed in bold type are examination and imaging findings Lodhia P, Suarez-Ahedo C, Domb BG: those published within the past 5 Outcomes of hip arthroscopy in patients that will guide treatment efforts. If years. with Tönnis grade-2 osteoarthritis at a the symptoms are similar to preop- mean 2-year follow-up: Evaluation using a matched-pair analysis with tönnis grade- 1. Cvetanovich GL, Chalmers PN, Levy DM, erative symptoms, then the patient 0 and grade-1 cohorts. J Bone Joint Surg et al: Hip arthroscopy surgical volume Am 2016;98:973-982. most likely had an incomplete trends and 30-day postoperative resection of the CAM or pincer complications. Arthroscopy 2016;32: 13. Skendzel JG, Philippon MJ, Briggs KK, deformity,7 or the incorrect diag- 1286-1292. Goljan P: The effect of joint space on midterm outcomes after arthroscopic hip nosis was made and surgery was not 2. Dwyer MK, Lee JA, McCarthy JC: surgery for femoroacetabular impingement. Cartilage status at time of arthroscopy indicated. In patients with arthritis, Am J Sports Med 2014;42:1127-1133. predicts failure in patients with hip there is unlikely to be notable relief dysplasia. J Arthroplasty 2015;30:121-124. 14. Malviya A, Raza A, Jameson S, James P, if advanced preoperative joint space Reed MR, Partington PF: Complications 3. Krych AJ, King AH, Berardelli RL, Sousa and survival analyses of hip arthroscopies narrowing. In patients with pain PL, Levy BA: Is subchondral acetabular performed in the National Health service in that is different from their preop- edema or cystic change on MRI a england: A review of 6,395 cases. contraindication for hip arthroscopy in erative symptoms, the most com- Arthroscopy 2015;31:836-842. patients with femoroacetabular mon causes are either iatrogenic impingement? Am J Sports Med 2016;44: 15. Duplantier NL, McCulloch PC, Nho SJ, 454-459. instability (likely due to capsular Mather RC, Lewis BD, Harris JD: Hip 23,48 deficiency or failure to close), 4. Saadat E, Martin SD, Thornhill TS, dislocation or subluxation after hip iatrogenic injury to the cartilage Brownlee SA, Losina E, Katz JN: Factors arthroscopy: A systematic review. associated with the failure of surgical Arthroscopy 2016;32:1428-1434. during surgery, or pain associated treatment for femoroacetabular 16. Larson CM, Pierce BR, Giveans MR: with rehabilitation (flexor tendini- impingement: Review of the literature. Am J Treatment of athletes with symptomatic Sports Med 2014;42:1487-1495. tis which may be associated with intra-articular hip pathology and athletic anterior groin pain or “burning” as 5. Larson CM, Ross JR, Stone RM, et al: pubalgia/sports hernia: A case series. Arthroscopy 2011;27:768-775. activity levels increase or soft-tissue Arthroscopic management of dysplastic hip deformities: Predictors of success and 17. Nwachukwu BU, Fields K, Chang B, irritation in the lateral aspect of failures with comparison to an arthroscopic Nawabi DH, Kelly BT, Ranawat AS: FAI cohort. Am J Sports Med 2016;44: the thigh). A number of commonly Preoperative outcome scores are predictive 447-453. encountered examples are seen in of achieving the minimal clinically Table 1. 6. 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However, due to the ANCHOR Investigators: Patient and Lindner D, Stake CE, Domb BG: Does complexity of the procedure and disease characteristics associated with hip obesity affect outcomes after hip arthroscopy failure in acetabular dysplasia. arthroscopy? A cohort analysis. J Bone potentially confounding factors, such J Arthroplasty 2014;29(9 suppl):160-163. Joint Surg Am 2015;97:16-23. as diagnosis, indications, technical 9. Collins JA, Beutel BG, Garofolo G, Youm 20. Philippon MJ, Schenker ML, Briggs KK, execution, and postoperative reha- T: Correlation of obesity with patient- Kuppersmith DA, Maxwell RB, Stubbs AJ: bilitation protocols, optimal out- reported outcomes and complications after Revision hip arthroscopy. Am J Sports Med comes after index hip arthroscopy hip arthroscopy. Arthroscopy 2015;31: 2007;35:1918-1921. 57-62. remain a challenge. Failure to ade- 21. Levy DM, Grzybowski J, Salata MJ, quately address each of these com- 10. Saltzman BM, Kuhns BD, Basques B, et al: Mather RC, Aoki SK, Nho SJ: Capsular The influence of body mass index on plication for treatment of iatrogenic hip ponents may result in persistent pain outcomes after hip arthroscopic surgery instability. Arthrosc Tech 2015;4: and disability after surgery. Treating with capsular plication for the treatment of e625-e630. femoroacetabular impingement. Am J surgeons must be able to identify Sports Med 2017;45:2303-2311. 22. Mei-Dan O, Garabekyan T, McConkey M, underlying reasons for failure after Pascual-Garrido C: Arthroscopic anterior 11. Frank RM, Lee S, Bush-Joseph CA, Salata capsular reconstruction of the hip for hip arthroscopy to successfully treat MJ, Mather RC, Nho SJ: Outcomes for hip recurrent instability. Arthrosc Tech 2015;4: affected patients. arthroscopy according to sex and age: A e711-e715.

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23. Wylie JD, Beckmann JT, Maak TG, Aoki (ANCHOR) Members. Persistent structural to iatrogenic instability: Can partial SK: Arthroscopic capsular repair for disease is the most common cause of repeat division of the ligamentum teres and symptomatic hip instability after previous hip preservation surgery. Clin Orthop Relat iliofemoral ligament cause subluxation? hip arthroscopic surgery. Am J Sports Med Res 2013;471:3788-3794. Arthroscopy 2012;28:440-445. 2016;44:39-45. 33. Cvetanovich GL, Harris JD, Erickson BJ, 41. Telleria JJM, Safran MR, Harris AHS, 24. Philippon MJ, Decker MJ, Giphart JE, Bach BR, Bush-Joseph CA, Nho SJ: Gardi JN, Glick JM: Risk of sciatic nerve Torry MR, Wahoff MS, LaPrade RF: Revision hip arthroscopy: A systematic traction injury during hip arthroscopy—Is Rehabilitation exercise progression for the review of diagnoses, operative findings, and it the amount or duration? An gluteus medius muscle with consideration outcomes. Arthroscopy 2015;31: intraoperative nerve monitoring study. J for iliopsoas tendinitis: An in vivo 1382-1390. Bone Joint Surg Am 2012;94:2025-2032. electromyography study. Am J Sports Med 2011;39:1777-1785. 34. Ross JR, Larson CM, Adeoye O, Adeoyo 42. Robertson WJ, Kelly BT: The safe zone for O, Kelly BT, Bedi A: Residual deformity is hip arthroscopy: A cadaveric assessment of 25. Cheatham SW, Enseki KR, Kolber MJ: the most common reason for revision hip central, peripheral, and lateral Postoperative rehabilitation after hip arthroscopy: A three-dimensional CT compartment portal placement. arthroscopy: A search for the evidence. J study. Clin Orthop Relat Res 2015;473: Arthroscopy 2008;24:1019-1026. Sport Rehabil 2015;24:413-418. 1388-1395. 26. Grzybowski JS, Malloy P, Stegemann C, 43. Domb BG, Stake CE, Lindner D, El-Bitar Y, 35. 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