TheJRGOS CASE CORNERissubmitted byKwadwo A Owusu-Akyaw MD FAAOS OrthoVirginia, Richmond, Co-Chair Hip Preservation OrthoVirginia Deputy Editor to Clinical Orthopaedics and Related Research (CORR) for Hip Arthroscopy, Board of Directors J Robert Gladden Orthopaedic Society (JRGOS).
Case Presentation
45 year-old Female presented with mechanical pain of the left hip present since 1995. She underwent left hip arthroscopy with flexor tendon release in 1995 followed by revision arthroscopy with labral repair in 2001.On presentation patient reported anterolateral hip pain made worse with ambulation, range of motion and limiting work activity.
She reported minimal pain relief with over 3 months of physical therapy, activity modification and home exercise program focused on restoration of strength to the dynamic hip stabilizers.Ultrasound guided intra-articular corticosteroid injection helped only temporarily.
On examination, patient demonstrated passive and active hip range of motion limited by pain, particularly with hip flexion and internal rotation with positive FADIR (flexion adduction internal rotation) test. And painful gait.
Diagnostic Imaging
Radiographs demonstrate well preserved joint space of the hip joint.
Fluid sensitive sagittal magnetic resonance imaging (MRI) confirmed post surgical changes from previous labral repair with complex, degenerative tearing of the anterosuperior labrum.
Treatment Plan
In the setting of failed conservative treatment and persistent pain secondary to failed previous hip arthroscopy and concern for labral insufficiency, via shared decision making process patient consented to proceed with revision hip arthroscopy with allograft labral reconstruction utilizingtensor fascia lata allograft tissue.
Intra-operatively, exposure to the hip joint was obtained utilizing the Stryker Pivot Guardian Postless Traction System.
Diagnostic Arthroscopy of the central compartment confirmed severe degeneration of the labral tissue with insufficiency of the suction seal.Patient chondral surfaces were well preserved on the femoral head and acetabulum (watch video).
Diagnostic Arthroscopy of the Peripheral Compartment confirmed presence of residual prominence of the anterolateral femoral head neck junction with concern for impingement. Revision osteochondroplasty of the femur was performed to address the impingement (watch video).
Circumferential labral reconstruction was performed with tensor fascia lata allograft. The graft was anchored to the acetabular rim with a series of 1.4 mm Stryker NanoTack anchors.After completion of the reconstruction, restoration of the suction seal of the hip was confirmed (watch video).
Repair of the inter-portal capsulotomy was performed utilizing#2 non absorbable sutures.
Post Operative Course
Early range of motion and gait training with physical therapy initiated 1 week post operatively. Patient mobilizing with crutches, wearing a hip range of motion post surgical brace. Partial, flat foot weight bearing maintained for 6 weeks after surgery.Weight bearing advanced gradually as tolerated and brace weaned once gait normalized under physical therapy supervision.
Pearls
Meticulous preparation of the acetabular rim and anchor placement to ensure proper restoration of suction seal after graft implantation
Careful capsular management with complete repair of the capsulotomy at the end of the case
Post-less traction system decreases risk for pudendal nerve traction injury or groin injury
