**3.2 Specific surgical procedures**

#### **3.2.1 Psoas tenotomy**

The indications for psoas tenotomy are tendonitis or painful internal snapping hip syndrome that have not improved with conservative treatment, in particular with

Arthroscopy after Total Hip Replacement Surgery 89

Fig. 8. Impingement of the acetabular rim of the implant on the lesser trochanter (white

Hip Bursitis and trochanteritis are treated by debridement in the same way as in non prosthetic hips. An early description of a bursectomy using bursoscopy was given by Bradley (Bradley & Dillingham, 1998). Problems related to the peritrochanteric space can be approached from the peripheral compartment or using the inside-outside technique, described by Ilizaliturri. We perform bursoscopy at a second stage following the arthroscopic examinatiooon of the hip joint. For this reason we tend to perform the technique from the peripheral compartment, reorienting the peritrochanteric portal. Aditionaly we use one or two portals, one distal and one proximal to the tip of the

A wide range of techniques can be used. These include debridement, trochanteric abrasion, z-tenotomy of the fascia lata and suture using anchors, depending on the condition to be treated. There is a great similarity between gluteus medius and minimus tears with shoulder rotator cuff injuries (Fig. 7 A), It is suspected that that their prevalence is higher than believed to date and that this condition may be responsible for many cases of pain in the trochanter region after hip replacement surgery. Treatment is similar and involves repair by

Fibrous structures are a potential cause of pain related to hip replacement surgery (Bajwa & Villar, 2011; Cuéllar et al. 2009; McCarthy et al., 2009). The symptoms in such cases are similar to those of iliopsoas tendonitis: inguinal pain radiating down the inner thigh and pain during activities involving flexion of the hip like climbing stairs and slopes, getting in and out of cars, and turning over in bed among others (Beck, 2009; Krueger et al., 2007). Often large longitudinal fan shaped fibrous adhesions, occupying the medial recess can be found (Cuéllar et al., 2009). (Fig-2). In these cases, mechanical debridement and thermo coagulation are performed, and any scar tissue around the joint the synovial plica is

asterisk) leading to dislocation of this right hip (white arrow)

placement of suture anchors (Cuéllar et al., 2010). (Fig. 7 B).

**3.2.3 Plica resection for arthrofibrosis** 

**3.2.2 Trochanterplasty - Gluteal muscle repair** 

trochanter.

resected.

ultrasound-guided steroid injections. We use the same concept and technique as those applied in cases of iliopsoas tendonitis in patients that have not had total hip replacement surgery. As standardised by Ilizaliturri, there are two ways to perform tenotomy (Ilizaliturri et al., 2009): 1) at its site of insertion on the lesser trochanter, and 2) along its course close to the joint. In the latter, the tendon can be partially seen behind the articular capsule or can be directly observed through an orifice that communicates the joint with the iliopectinea bursa.

Fig. 6. Psoas tenotomy: Tenotomy at the level of the acetabular rim (A). Release of the tendinous fibres up to the level of the muscle fibres (B)

Fig. 7. Gluteal muscle tears in a right hip, seen through the distal peritrochanteric portal: A) similarity to rotator cuff ttears, B) repair with suture anchors

The psoas tendon is divided close to the acetabular component in the cases in which there is evident acetabular involvement (Fig. 6 A, B A, B). If this is not clear, the tenotomy is performed near the lesser trochanter. In any case, only the tendinous fibres are releasd , stopping the intervention when the muscular fibres are reached (Fig. 6 B).

ultrasound-guided steroid injections. We use the same concept and technique as those applied in cases of iliopsoas tendonitis in patients that have not had total hip replacement surgery. As standardised by Ilizaliturri, there are two ways to perform tenotomy (Ilizaliturri et al., 2009): 1) at its site of insertion on the lesser trochanter, and 2) along its course close to the joint. In the latter, the tendon can be partially seen behind the articular capsule or can be directly observed through an orifice that communicates the joint with the iliopectinea bursa.

Fig. 6. Psoas tenotomy: Tenotomy at the level of the acetabular rim (A). Release of the

Fig. 7. Gluteal muscle tears in a right hip, seen through the distal peritrochanteric portal: A)

The psoas tendon is divided close to the acetabular component in the cases in which there is evident acetabular involvement (Fig. 6 A, B A, B). If this is not clear, the tenotomy is performed near the lesser trochanter. In any case, only the tendinous fibres are releasd ,

tendinous fibres up to the level of the muscle fibres (B)

**A B**

similarity to rotator cuff ttears, B) repair with suture anchors

**A B**

stopping the intervention when the muscular fibres are reached (Fig. 6 B).

Fig. 8. Impingement of the acetabular rim of the implant on the lesser trochanter (white asterisk) leading to dislocation of this right hip (white arrow)

#### **3.2.2 Trochanterplasty - Gluteal muscle repair**

Hip Bursitis and trochanteritis are treated by debridement in the same way as in non prosthetic hips. An early description of a bursectomy using bursoscopy was given by Bradley (Bradley & Dillingham, 1998). Problems related to the peritrochanteric space can be approached from the peripheral compartment or using the inside-outside technique, described by Ilizaliturri. We perform bursoscopy at a second stage following the arthroscopic examinatiooon of the hip joint. For this reason we tend to perform the technique from the peripheral compartment, reorienting the peritrochanteric portal. Aditionaly we use one or two portals, one distal and one proximal to the tip of the trochanter.

A wide range of techniques can be used. These include debridement, trochanteric abrasion, z-tenotomy of the fascia lata and suture using anchors, depending on the condition to be treated. There is a great similarity between gluteus medius and minimus tears with shoulder rotator cuff injuries (Fig. 7 A), It is suspected that that their prevalence is higher than believed to date and that this condition may be responsible for many cases of pain in the trochanter region after hip replacement surgery. Treatment is similar and involves repair by placement of suture anchors (Cuéllar et al., 2010). (Fig. 7 B).

#### **3.2.3 Plica resection for arthrofibrosis**

Fibrous structures are a potential cause of pain related to hip replacement surgery (Bajwa & Villar, 2011; Cuéllar et al. 2009; McCarthy et al., 2009). The symptoms in such cases are similar to those of iliopsoas tendonitis: inguinal pain radiating down the inner thigh and pain during activities involving flexion of the hip like climbing stairs and slopes, getting in and out of cars, and turning over in bed among others (Beck, 2009; Krueger et al., 2007).

Often large longitudinal fan shaped fibrous adhesions, occupying the medial recess can be found (Cuéllar et al., 2009). (Fig-2). In these cases, mechanical debridement and thermo coagulation are performed, and any scar tissue around the joint the synovial plica is resected.

Arthroscopy after Total Hip Replacement Surgery 91

To date, we have only treated one case of impingement of the edge of the acetabular component on the lesser trochanter. This impingement caused dislocation of the prosthesis (Bajwa & Villar, 2011; Cuéllar et al., 2010). (Fig-8). Preoperative investigations (X-ray and CT scan) showed a short femoral neck leading to cam impingement with a head/neck ratio <2. Arthroscopy-guided exploration confirmed the presence of impingement between the lesser trochanter and the inferior edge of the acetabulum in external rotation which caused prosthesis dislocation and left redundant capsular tissue in the anterior and lateral recesses. The bone across all the contact area between the lesser trochanter and the prosthetic acetabulum was shaved away until the impingement disappeared. This was combined with

In cases of instability, plication of redundant capsular tissue is performed. This is achieved by threading a double no. 2 suture through parallel incisions in the capsule secured with a loop knot, in a similar manner to the technique described for the treatment of instability of a

Surgery is indicated after failure of conservative treatment with Physiotherapy and muscle

A CT scan should be carried out to confirm that there is no significant acetabular

Before proceeding with surgery, a EUA is carried out under X ray control looking for

The main operative finding often is the presence of a large capsular recess generally located in the lateral and posterior aspects of the hip joint (Fig. 9 A, B). Capsular plicature is preceded by dissecting the capsular plane from the underlying muscle (Fig. 9 C, D), using a blunt dissector. In the posterior recess, this is carried out through a posterior and lateral approach and supported in the muscular plane of the lateral rotator group of muscles (obturator externus, gemelli). The sciatic nerve runs laterally and is protected by this muscular plane. In the anterior plane, we dissect the capsular plane from the rectus femoris. Once the capsular plane to be plicated has been freed, we make two or three parallel incisions with a scalpel. Through these, we thread a double no. 2 suture in and out using a bird-beak passer leaving an end loop (Fig. 9 E). Subsequently, one end of the suture is brought through the end loop. Finally, the two ends of the suture are knotted, gathering up the redundant capsular volume, like a tobacco pouch" (Fig. 9 F, G). The procedure can be repeated in other regions of the capsule as many times as necessary to obtain sufficient reduction of the redundant capsular volume (Fig. 9 H, I). During this procedure laxity is

In the postoperative period no orthosis is usually required. Patients are, however, given guidance concerning how to avoid movements that might cause new dislocations and instructed to perform exercises to strengthen the glutei muscles. Patients are discharged 24

In our experience, it was possible to gain access to the prosthetic joint with the arthroscopic instruments in all cases. This was technically more demanding in cases of arthrofibrosis

non-prosthetic hip (Shindle et al., 2006; Tibor & Sekiya, 2008). (Fig. 9).

strength rehabilitation focussed in the trochanteric and pelvic region.

checked until all signs of instability have disappeared.

anteversion or retroversion nor signs of prosthetic components loosening.

**3.2.4 Abrasion for impingement** 

capsulorraphy, as described below.

**3.2.5 Capsular plicature** 

instability or snapping.

to 48 hours after surgery

**4. Clinical evidence** 

Fig. 9. Capsular plicature technique: A) Redundant capsular tissue in a case of an unstable THR; B) illustration of the technique used in cases of instability, by threading a double no. 2 suture through parallel incisions secured with a loop knot; C) Dissection of the capsular plane from the underlying muscle using a blunt dissector; D) once the capsular plane has been freed; E) two or three parallel incisions are made in the redundant capsule. A double no. 2 suture is threaded in and out through alternate incisions using a bird-beak passer; F) An end loop is left; G) one end of the suture is brought through the end loop and the two ends of the suture are knotted; H) the procedure can be repeated; I) until sufficient reduction of the redundant capsular volume is achieved.

#### **3.2.4 Abrasion for impingement**

90 Modern Arthroscopy

**A B C**

**D E F**

**G H I**

Fig. 9. Capsular plicature technique: A) Redundant capsular tissue in a case of an unstable THR; B) illustration of the technique used in cases of instability, by threading a double no. 2 suture through parallel incisions secured with a loop knot; C) Dissection of the capsular plane from the underlying muscle using a blunt dissector; D) once the capsular plane has been freed; E) two or three parallel incisions are made in the redundant capsule. A double no. 2 suture is threaded in and out through alternate incisions using a bird-beak passer; F) An end loop is left; G) one end of the suture is brought through the end loop and the two ends of the suture are knotted; H) the procedure can be repeated; I) until sufficient reduction

of the redundant capsular volume is achieved.

To date, we have only treated one case of impingement of the edge of the acetabular component on the lesser trochanter. This impingement caused dislocation of the prosthesis (Bajwa & Villar, 2011; Cuéllar et al., 2010). (Fig-8). Preoperative investigations (X-ray and CT scan) showed a short femoral neck leading to cam impingement with a head/neck ratio <2.

Arthroscopy-guided exploration confirmed the presence of impingement between the lesser trochanter and the inferior edge of the acetabulum in external rotation which caused prosthesis dislocation and left redundant capsular tissue in the anterior and lateral recesses. The bone across all the contact area between the lesser trochanter and the prosthetic acetabulum was shaved away until the impingement disappeared. This was combined with capsulorraphy, as described below.

#### **3.2.5 Capsular plicature**

In cases of instability, plication of redundant capsular tissue is performed. This is achieved by threading a double no. 2 suture through parallel incisions in the capsule secured with a loop knot, in a similar manner to the technique described for the treatment of instability of a non-prosthetic hip (Shindle et al., 2006; Tibor & Sekiya, 2008). (Fig. 9).

Surgery is indicated after failure of conservative treatment with Physiotherapy and muscle strength rehabilitation focussed in the trochanteric and pelvic region.

A CT scan should be carried out to confirm that there is no significant acetabular anteversion or retroversion nor signs of prosthetic components loosening.

Before proceeding with surgery, a EUA is carried out under X ray control looking for instability or snapping.

The main operative finding often is the presence of a large capsular recess generally located in the lateral and posterior aspects of the hip joint (Fig. 9 A, B). Capsular plicature is preceded by dissecting the capsular plane from the underlying muscle (Fig. 9 C, D), using a blunt dissector. In the posterior recess, this is carried out through a posterior and lateral approach and supported in the muscular plane of the lateral rotator group of muscles (obturator externus, gemelli). The sciatic nerve runs laterally and is protected by this muscular plane. In the anterior plane, we dissect the capsular plane from the rectus femoris. Once the capsular plane to be plicated has been freed, we make two or three parallel incisions with a scalpel. Through these, we thread a double no. 2 suture in and out using a bird-beak passer leaving an end loop (Fig. 9 E). Subsequently, one end of the suture is brought through the end loop. Finally, the two ends of the suture are knotted, gathering up the redundant capsular volume, like a tobacco pouch" (Fig. 9 F, G). The procedure can be repeated in other regions of the capsule as many times as necessary to obtain sufficient reduction of the redundant capsular volume (Fig. 9 H, I). During this procedure laxity is checked until all signs of instability have disappeared.

In the postoperative period no orthosis is usually required. Patients are, however, given guidance concerning how to avoid movements that might cause new dislocations and instructed to perform exercises to strengthen the glutei muscles. Patients are discharged 24 to 48 hours after surgery

#### **4. Clinical evidence**

In our experience, it was possible to gain access to the prosthetic joint with the arthroscopic instruments in all cases. This was technically more demanding in cases of arthrofibrosis

Arthroscopy after Total Hip Replacement Surgery 93

Arthroscopy can be successfully applied to the diagnosis and treatment of pain of unknown origin after hip replacement surgery. This very often associated with lumbar spine disorders, other medical conditions and old age. This association makes the differential

The technique has proven to be especially useful in the treatment of instability, muscular

On the other hand, the technique has not been found to be reliable for identifying cases of

Adler, R.S.; Buly, R.; Ambrose, R. & Sculco, T. (2005). Diagnostic and therapeutic use of

Bajwa, A.R. & Villar, S.N. (2011). Arthroscopy of the hip in patients following joint

Barrack, R.L., Butler, R.A. Laster, D.R. & Andrews, P. (2001). Stem desing and dislocation

Barrack, R.L. (2003). Dislocation after total hip arthroplasty: implant design and orientation.

Beaulé, P.E.; Schmalzriued, T.P.; Udomkiat, P. & Amstutz, H.C. (2002). Jumbo femoral

Beck, M. (2009). Groin pain alter open FAI surgery. *Clinical Orthopaedics and Related Research*,

Bohl, W. & Steffee, A. (1979). Lumbar spinal stenosis: a cause of continued pain and

Bourne, R.B.; Rorabeck, C.H., Ghazal, M.E. & Lee, M.H. (1994). Pain in the thigh following

Bocell, J.R.; Thorpe, C.D. & Tullos, H.S. (1991). Arthroscopic treatment of symptomatic total

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**6. Conclusions** 

diagnosis difficult.

**7. References** 

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loosening of prosthetic components.

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where the fibrous bands make the cavity difficult to visualize and therefore more time is required to perform the debridement procedure.

At follow up, three months after surgery, patients that underwent psoas tenotomy had recovered the range of hip flexion to grade 4 and by 6 months all patients had regained grade 5 strength.

We have found that patients with lumbar spine disorders experience more back and radiating leg pain after having their painful prosthetic hips treated.

In all the cases of capsulorraphy the instability and the episodes of subluxation had disappeared. This was maintained at the 6-month and 1-year follow-ups. None of the patients had to undergo further surgery in relation to their hip replacement. They were given instructions to avoid hip flexion of more than 100º, especially together with external rotation and adduction.

We have not observed any neurovascular complications.

#### **5. Discussion**

In 1% of the cases the reason for the persistence of pain following hip replacement surgery remains unknown (Witvoët, 2001). Despite this, the cause of pain should always be investigated and we should not rush in carrying out revision surgery (Witvoët, 2001). This is where arthroscopy plays an important role enabling a progress in the diagnosis and a potential treatment in certain patients whose prostheses, although apparently properly implanted, continue to cause pain (McCarthy et al., 2009). This is already being used as a diagnostic and therapeutic tool in some painful complications associated with total knee replacements (Bocell et al., 1991; Johnson et al., 1990; Lawrence & Kan, 1992; Lucas et al., 1999; Markel et al., 1996; Scranton, 2001; Tzagarakis et al., 2001; Wasilewski & Frankl, 1989a, 1989b).

Access can be gained to the prosthetic joint using the arthroscopic technique and instruments. It is possible to apply this to resurfacing type prostheses, as indicated in the only paper that we found on this topic (Khanduja & Villar, 2008).

We favour capsular plication using sutures rather than thermal methods.

Regarding the use of ultrasound-guided steroid injections into the psoas (Adler et al., 2005; Ala Eddine et al., 2001; Bricteaux et al., 2000; Dora et al., 2007; O'Sullivan et al., 2007; Wank et al., 2004), we believe that this technique has few advantages: it is not easy to perform; and in our opinion doesn´t provide much information, even in cases in which it was clear intraoperatively that there was tendon involvement. The outcomes reported in the literature are very variable and it is often not successful (Adler et al., 2005; Ala Eddine et al., 2001; Bricteaux et al., 2000; Cuéllar et al., 2009; Jasani et al., 2002; McCarthy et al., 2009; O'Sullivan et al., 2007; Witvoët, 2001). For this reason, we recommend that this technique is not used systematically, but rather only in selected cases.

It is possible to perform endoscopy-guided trochanteric bursoscopy and fasciotomy. Additionally, if necessary, gluteal muscle repair can be performed.

To date we have not treated any patients with acute or subacute arthritis, but we believe that the arthroscopy technique could be used in such cases, similarly to when indicated in infected total knee replacements (Hyman et al., 1999; McCarthy et al., 2009).

To avoid prosthetic dislocation in the immediate postoperative period, unnecessary wide capsulotomies should not be done, and the patents should be given clear instructions about postural training (Cuéllar et al., 2009).
