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Editorial Commentary: Repeat Revision Hip Arthroscopy: Unaddressed Femoroacetabular Impingement, Labral Damage, and Capsular Deficiency Are Commonly Encountered

      Abstract

      The increasing use of hip arthroscopy has been accompanied by an associated increase in revision hip arthroscopy. The results of revision surgery are generally inferior to primary hip arthroscopy. When revision hip arthroscopy fails, repeat revision hip arthroscopy may be indicated. Addressing the etiology of failure of the primary and first revision surgery is fundamental to achieving optimal outcomes in repeat revision cases. Unfortunately, poorly executed previous surgery is the leading etiology of failure, with unaddressed femoroacetabular impingement, labral damage, and capsular deficiency most commonly encountered during repeat revision surgery. Complex secondary soft-tissue procedures may be required to address capsular and labral deficiency from previous surgery. Despite clinically significant improvement in repeat revision cases, results are inferior to those after primary hip arthroscopy. The best opportunity for a patient to achieve an optimal outcome is a well-executed primary surgery.
      There is a fundamental rule in golf that can be applied to hip arthroscopy. When you hit your golf ball into the woods, the first thing you should do is get it back into the fairway. You might not par the hole, but it is critical to get pointed back in the right direction to avoid disaster. A poorly executed shot that ends up further in the woods may result in a lost ball. When a patient has a bad outcome after a hip arthroscopy, the first thing to do is to get him or her pointed back in the right direction. A well-executed revision hip arthroscopy may not achieve equivalent improvement to “getting it right the first time,” but it can lead to significant improvement. A poorly executed revision hip arthroscopy may lead to disaster for the patient. If at first you don’t succeed, try, try again.
      Revision revision hip arthroscopy is the subject of the article by Drs. Browning, Clapp, Krivicich, Nwachukwu, Chahla, and Nho entitled, “Repeat Revision Hip Arthroscopy Outcomes Match That of Initial Revision but Not That of Primary Surgery for Femoroacetabular Impingement Syndrome.”
      • Browning R.B.
      • Clapp I.M.
      • Krivicich L.M.
      • Nwachukwu B.U.
      • Chahla J.
      • Nho S.J.
      Repeat revision hip arthroscopy outcomes match that of initial revision but not that of primary surgery for femoroacetabular impingement syndrome.
      The second “revision” in the previous sentence is not a typo. This study investigates the results after a subsequent revision hip arthroscopy after the first revision failed. To continue the golfing analogy, this would be like hitting a second shot from out of the woods when the first shot failed to escape. This article serves to provide hope to all hip arthroscopists that all is not lost when a patient fails a revision arthroscopy. Patients can achieve clinically significant improvement after second-time revision hip arthroscopy, albeit to a lower level than after primary surgery.
      In a recent large cross-sectional study of more than 50,000 patients who underwent hip arthroscopy between 2010 and 2017, the rate of revision arthroscopy was 15.1% within 2 years of the index surgery.
      • Cevallos N.
      • Soriano K.K.J.
      • Flores S.E.
      • Wong S.E.
      • Lansdown D.A.
      • Zhang A.L.
      Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
      The rate of conversion to total hip arthroplasty was 3.9%. This 19% failure rate underscores the inherent difficulty in “getting it right the first time,” as poorly executed primary surgery is the leading cause of failure. Unaddressed or inadequately corrected osseous impingement compromises joint mechanics and risks continued damage to the cartilage and repaired labrum.
      • Heyworth B.E.
      • Shindle M.K.
      • Voos J.E.
      • Rudzki J.R.
      • Kelly B.T.
      Radiologic and intraoperative findings in revision hip arthroscopy.
      • Clohisy J.C.
      • Nepple J.J.
      • Larson C.M.
      • Zaltz I.
      • Millis M.
      Academic Network of Conservation Hip Outcome Research (ANCHOR) Members. Persistent structural disease is the most common cause of repeat hip preservation surgery.
      • Gwathmey F.W.
      • Jones K.S.
      • Thomas Byrd J.W.
      Revision hip arthroscopy: Findings and outcomes.
      Soft-tissue factors such as labral retear, labral deficiency, chondral injury, capsulolabral adhesions, and/or capsular dehiscence or deficiency perpetuate joint dysfunction and may lead to mechanical symptoms and microinstability.
      • Arakgi M.E.
      • Degen R.M.
      Approach to a failed hip arthroscopy.
      Revision hip arthroscopy must address the etiology of failure to be successful. While positive results can be achieved, the outcomes after revision hip arthroscopy are generally inferior to those after primary hip arthroscopy.
      • Shapira J.
      • Kyin C.
      • Go C.
      • et al.
      Indications and outcomes of secondary hip procedures after failed hip arthroscopy: A systematic review.
      A successful redo revision hip arthroscopy requires understanding what went wrong the first and second time. In the current study, many of the factors that doom primary hip arthroscopy were found to be the cause of failure of the revision surgery with recurrent labral tear, residual cam-type impingement, and capsular defects seen in a majority of cases. Perfecting the bony morphology clearly had a role in the repeat revision surgeries, with 65% undergoing acetabular rim trimming and 85% undergoing femoral osteochondroplasty. However, bony correction was performed less often in the repeat revision setting than both the primary and first revision surgery highlighting the central importance of soft tissue considerations. Labral reconstruction was performed in 15% of repeat revision cases, emphasizing the need to restore the labral function and seal compromised from previous surgery. All the repeat revision patients underwent some type of comprehensive capsular management, with one half requiring a capsular reconstruction. These data highlight the importance of the intact capsule to the function of the hip. It also provides a tangible signal of the evolution of hip arthroscopy. The days of performing a large capsulectomy for exposure and leaving the capsule unclosed are in the past. Successful outcomes require meticulous and comprehensive capsular management.
      Patients improved after repeat revision hip arthroscopy, achieving a minimal clinically important difference at a significantly greater rate than first-time revision patients and a similar rate to primary patients. Why would the repeat revision group outperform the revision group? The authors proposed that the lower preoperative scores in the repeat revision group allowed for a larger magnitude of improvement and consequently a better probability of reaching the minimal clinically important difference threshold. In other words, they had much more room for improvement. Achieving patient acceptable symptomatic state, however, proved to be more difficult in the redo revision group due to these lower preoperative scores. Although redo revision patients achieved meaningful improvement, their ultimate outcome was inferior to that of the primary hip arthroscopy group, with only 30% achieving patient acceptable symptomatic state on one or more outcomes score compared with 76.7% in the primary group.
      The findings of this study lead me to 2 important conclusions. The first is that I should not give up on the 2-time failure. The patients who underwent redo revision in this study had abysmal preoperative scores. The mean preoperative modified Harris Hip Score of 46.3 implies that these patients are severely limited. With a well-executed repeat revision, 90% of patients can expect clinical improvement. They many need complex revision procedures such as labral or capsular reconstruction, but sometimes, all a struggling patient needs is hope, which these data provide.
      My second conclusion from this study is that it is imperative for me as a hip arthroscopist to “get it right the first time.” The operative findings and procedures performed in the redo revision surgeries elucidate the osseous and soft-tissue factors that caused the index and first revision surgery to fail. I need to help patients avoid the redo revision situation by being cognizant of these potential causes of failure. The first surgery is the best opportunity to adequately address the pathology underlying the symptoms. After a redo revision surgery, only 3 in 10 patients can expect to achieve an acceptable symptomatic state. Most patients (7 of ten to be exact) would find that result unacceptable.
      Revisiting my golf analogy, only the best golfers can consistently salvage a shot from the woods. It requires great skill as well an understanding of the course and the elements to put the ball back into the fairway and save the hole. A surgeon needs to possess great skill and a thorough understanding of the factors that produced a bad outcome to perform a successful revision or redo revision hip arthroscopy. I think most golfers would agree that consistently putting the first shot into the fairway and avoiding the woods altogether is the best way to achieve a good score. Most surgeons would agree that “getting it right the first time” is the best way to achieve optimal outcomes.

      Supplementary Data

      References

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        Repeat revision hip arthroscopy outcomes match that of initial revision but not that of primary surgery for femoroacetabular impingement syndrome.
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        • Flores S.E.
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        Hip arthroscopy volume and reoperations in a large cross-sectional population: High rate of subsequent revision hip arthroscopy in young patients and total hip arthroplasty in older patients.
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        • Nepple J.J.
        • Larson C.M.
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