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John J Christoforetti, MD Pittsburgh, Pennsylvania, USA

What is the role of Hip arthroscopy in the recurrent unstable hip? Capsular Instability and insufficiency. John J Christoforetti, MD Pittsburgh, Pennsylvania, USA. John j christoforetti , md. I have financial relationships with the following companies:

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John J Christoforetti, MD Pittsburgh, Pennsylvania, USA

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  1. What is the role of Hip arthroscopy in the recurrent unstable hip?Capsular Instability and insufficiency John J Christoforetti, MD Pittsburgh, Pennsylvania, USA

  2. John j christoforetti, md I have financial relationships with the following companies: Consulting: Arthrex, Inc. Breg, Inc Royalties: Arthrex, Inc.

  3. Hip instability defined • Traumatic • Forceful dislocation of the femoroacetabular joint • Atraumatic • Dislocation occurs with normal ADL or sleep • Chronic • Prolonged unrecognized dislocation • Recurrent • Repeat dislocation of femoroacetabular joint following reduction • Repeat subluxations leading to symptoms • Hip gives way • Hip pain/ache • CoxaSaltans

  4. Recurrent instability: Frank Instability Cases reported: Typically Posterior Typically associated with bone defects Typically posterior wall rim fractures Reported treatments typically OPEN procedures capsular shift bone block augmentations Anchor Repairs

  5. What does the literature tell us?Recurrent posterior dislocations • Hohmann (1964) • Aufranc, Jones, Harris (1964) • Liebenberg (1969) • Birmingham (2010)

  6. What does the literature tell us?Recurrent posterior dislocations • Rare without bone deficiency • May be associated with inadequate immoblization post index dislocation • Capsular “attenuation” and/or “enlarged synovial compartment” • Labrum may or may not be torn

  7. What does the literature tell us?Recurrent posterior dislocations • Treatments involve suture or suture anchor repair via open posterior approach • May also require bone block augmentation

  8. Repair of posterior structures Atlcheck et al JBJS

  9. What about recurrent anterior dislocations? • Dall (1970) • Large anterior pseudo capsule • No labrum tear • Extensile anterior approach • Femoral DerotationalOsteotomy • Psoas transfer • Capsule excision / plication • Postoperative immobilization in bilateral below knee spica

  10. What about Arthroscopy? • No reports for posterior recurrent dislocation • Philippon 2010: • recurrent low energy anteroinferior dislocation • Lateral/anterolateral portals • Plication plus labrum repair

  11. Decision for arthroscopy in recurrent hip dislocation in 2012 • Understand the pathology • Direction of dislocation: anterior anteroinferiorobturator posterior • Energy level of index AND recurrent mechanisms • Associated pathology? • Fracture of acetabulum, femoral head, both • Underlying skeletal morphology: dysplastic? pincer? Cam? Other? • “big trauma” issues • IF SOFT TISSUE FAILURE WITHOUT BONE DEFICIENCY OR ASSOCIATED MAJOR ISSUES, CONSIDER ARTHROSCOPY

  12. Radiograph evaluation: decision making • Plain radiographs • AP/Lateral • Some suggest Judet views • CT scan recommended • Small associated bone fragments • “plastic”deformity of old fracture healing

  13. Radiograph evaluation: Decision making • MRI without contrast • Search for effusion, associated pathology • MRI with arthrogram • Look for dye extravasation to guide location of capsular defect or psuedocapsule

  14. Physical examination • Awake exam: gait, apprehension free range of motion, global laxity findings, neurovascular exam • Exam Under Anesthesia: • ? Stable range of motion • ? Hip Distraction test

  15. Surgical solution: principles • Visualize, recognize ALL pathology correlated with instability direction • Typically posterior pathology • Short rotators/ capsule/ labrum • Repair vs augmented reconstruction of damage zone • Bone block / capsular advancement / allograft versus autograft tissue • Use preoperative imaging and exam to guide selection of approach

  16. Open Surgical Challenges • Approach challenging • Soft tissue planes distorted with scar • Neurovascular dissection (posterior) • AVN concerns

  17. Therefore, the role for arthroscopy is . . . • Limited • Isolated posterior labrum tear in posterior hip dislocation • Recurrent anterior/anteroinferior instability not associated with major abdominal or neurovascular injury, severe underlying skeletal anomaly (anteversion, fracture, dysplasia) • Recurrent subluxations / instability symptoms in patients with prior hip dislocation and the above exclusions

  18. Arthroscopic technique options • Labrum repair • Capsular repair • Ligament/ligament • ligament to bone (suture anchor) • Capsular plication Safran. MR et al J Arthroscopy

  19. Thank you! John Christoforetti, MD

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