Page 32 - ISAKOS 2021 Newsletter Volume 1

CURRENT CONCEPTS
Complications Following Arthroscopic Surgery of the Hip
If the traction time was >60 minutes, the odds ratio increased to 4.4 (95% confidence interval, 1.9 to 10). The rates reported in those three reports (22%, 37%, and 62.7%, respectively) were significantly higher than that in our review (0.9%). This finding certainly suggests that patient-reported outcomes do not necessarily converge with physician- measured outcomes. In addition, all of those recent studies focused on symptoms related to nerve dysfunction immediately postoperatively, and it is likely that the studies in our review evaluated the final outcome only, by which time most of the neuropraxia had resolved. Furthermore, the targeted studies in our review tended to avoid discussing sex-related complications such as neuropraxia of the pudendal nerve in younger patients, which may have led to a lower complication rate being reported compared with the more recent studies.
Distraction injuries often involve the femoral, sciatic, or peroneal nerves and may be caused by excessive traction or a prolonged traction time. It is recommended that surgeons should limit the force of traction to <50 lb (22.7 kg) to prevent these injuries5, and the continuous traction time should not exceed 1 hour.
Iatrogenic Chondral and Labral Injuries
Iatrogenic chondral and labral injuries were the second most common complication (0.7%). A total of 30 (10.8%) of the 276 articles described chondral or labral damage; therefore, only 254 (0.7%) of all 36,761 hips undergoing an arthroscopy were recorded. Thus, it is likely that these complications were underreported.
Injury to the acetabular labrum and articular cartilage occur relatively frequently in patients undergoing hip arthroscopy. When establishing the anterolateral portal, there is a risk of puncturing the superior and anterosuperior labrum.
Iatrogenic damage to the articular cartilage normally takes place on the femoral head, especially if there is insufficient traction. A minimum distraction of 10 mm followed by an intra-articular injection of 20 mL of normal saline solution for distension of the joint is recommended at the time of creation of the first portal in order to prevent damage to the femoral head and labrum. Furthermore, when the joint is filled with 20 mL of normal saline solution, the labral silhouette is observed on the image intensifier, which also allows safe access to the joint and avoids iatrogenic injury to the labrum. If adequate distraction cannot be achieved, it is recommended that the peripheral compartment is accessed first in order to allow for the placement of a guidewire into the central compartment under direct vision.
Heterotopic Ossification
Heterotopic ossification was the third most common complication (0.6%) in our review. Heterotopic ossification may occur as a result of surgical trauma to the gluteal muscles and bone debris from the osteoplasty when treating femoroacetabular impingement. This complication can be prevented by carefully clearing any bone fragments at the end of surgery and administration of pharmacological prophylaxis (e.g., indomethacin) for 4-6 weeks. Furthermore, larger capsulotomies should be avoided in order to prevent further extravasation of bone debris; if capsulotomy is performed, then capsular closure should be followed by a thorough washout of the joint.
Conclusion
Our review of 36,761 arthroscopies indicates that arthroscopic surgery of the hip is associated with a relatively low rate of complications, although some complications may be significant in young patients. The overall rate of complications was 3.3%, and the rate of major complications was 0.2%. We hope that this information will be of value to surgeons performing this procedure and to the patients undergoing it.
References
1. Tagaki K. The arthroscope: the second report. J Jpn Orthop Assoc. 1939;(14):441–66. 2. Nakano N, Lisenda L, Jones TL, et al. Bone Joint J. 2017 Dec;99-B(12):1577-1583. doi: 10.1302/0301-620X.99B12. BJJ-2017-0043.R2. Review. PMID: 29212679 3. Frandsen L, Lund B, Nielsen TG, et al. Traction-related problems after hip arthroscopy. J Hip Preserv Surg. 2017;4:54–59. 4. Reda B, Wong I. Postoperative numbness. A survey of patients after hip arthroscopic surgery. Orthop J Sports Med. 2018;6 2325967118771535. 5. Mas Martinez J, Sanz- Reig J, Morales Santias M, et al. Femoroacetabular impingement: prospective study of rate and factors related for nerve injury after hip arthroscopy. J Orthop. 2019 Apr 8;16(5):350-353. doi: 10.1016/j. jor.2019.03.017.
30 ISAKOS NEWSLETTER 2021: VOLUME I