Arthroscopic Management of Other Hip Disorders

Introduction

Complications of the posterior and posterolateral aspects of the hip have been extremely uncommon. A comprehensive understanding of the anatomy, biomechanics, clinical evaluation, and diagnostic strategies allows the physician to interpret the vast array of pathologies routinely encountered in the lateral and posterior hip. The comprehensive physical examination will help sort out the levels of pathology of the hip, including pathology involving the osseous, capsulolabral, musculotendinous, neurovascular, and kinematic chain ( Fig. 43.1 ). The kinematic chain in this region involves the pelvis and lumbar spine. The function of the hip as the longest lever and shortest lever arm contributes significantly to the strain parameters that are loaded downstream through the ligamentous structures, pelvis, and lower lumbar spine, and into the lower extremity. The critical factor involved with this load transfer is the planar torsional parameters in all three planes.

Hip arthroscopy has evolved since the original paper by Watanabe, and has further developed through time. Reports by Larson et al. ^, described the most common complications encountered with hip arthroscopy to be postoperative lateral femoral cutaneous nerve disturbance, iatrogenic chondral injuries and labral punctures, and superficial portal infections. The lateral-based technologies and our understanding of lateral-based pathology were further developed by Nawabi et al. through the peritrochanteric space endoscopy with minimal complications. Surgical strategies for the posterior hip have advanced circumferentially around the hip from the lateral to the posterior spaces. Posterior hip treatment techniques involving hamstring repair, lesser trochanterplasty, and sciatic nerve decompression from scar vascular bands or aberrant tendinous structures have been reported, with low complication rates. ^{, , ,} This chapter will address the potential complications encountered during treatment of the lateral and posterior hip. The lateral and posterior regions will be further analyzed through each aspect of the patient encounter, including the preoperative, intraoperative, and postoperative time periods.

The goal for any surgery is to have an accurate diagnosis that accounts for all five levels of the hip. Insufficient understanding of hip anatomy and biomechanics have led to improper surgical selection in many patients. Proper education will guide outlining an appropriate plan for each of the five levels. Diagnostic strategies surrounding each of these five levels is critical for improving diagnostic acumen and patient safety. An incorrect diagnosis will likely lead to unfortunate complication, regardless of surgical expertise. A comprehensive evaluation encompassing a thorough history and physical examination will help most importantly to identify the correct pathophysiology and supply a treatment algorithm.

Lateral hip pathology encompasses peritrochanteric pain syndrome and torn gluteus minimus/medius muscles. Patients presenting with these specific pathologies usually complain of pain over the lateral aspect at the hip, which is increased by rising from a chair or climbing stairs. Pain is located over the anterior, lateral, or posterior facet. The anterior facet is more associated with tears involving the gluteus minimus, whereas the lateral facet is associated with the gluteus medius, and the posterior facet with increased tension or thickness within the iliotibial (IT) band. These pathologies can be identified through strength testing with abduction and adduction maneuvers, which evaluate overall tension and function. They frequently coexist with intraarticular complaints and should be sorted out. The most likely complication of lateral-based pathology is failure to recognize the lateral pathology contribution to the overall pathological symptoms. Table 43.1 provides a summary of the key preoperative, intraoperative, and postoperative complications associated with lateral hip- and posterior hip-based complaints. All phases of the treatment require understanding of the shared responsibility between the patient and caregivers to optimize outcome.

Preoperative Complications