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LETTERS TO THE EDITOR Library. LILACS. Available at: http://lilacs.bvsalud.org/en. Accessed October 2, 2014. Ejnisman L, Lipai RR, Cabrita HB, et al. Arthroscopic treatment of hip pathology in 35 athletes. Rev Bras Med 2011;68:6-10. Comba F, Buttaro M, Piccaluga F. Arthroscopic treatment of cam type femoroacetabular impingement of the hip: Surgical technique and initial results. Artrosc (B Aires) 2010;17:43-49. Mardones R, Tomic A, Vega R, Orrego M. Arthroscopic treatment of femoroacetabular impingement: Surgical technique and early results. Rev Argent Artroscop 2006;13:90-101. Polesello GC, Lima FR, Guimaraes RP, Ricioli W, Queiroz MC. Arthroscopic treatment of femoroacetabular impingement: Minimum five-year follow-up. Hip Int 2014;24:381-386.
Regarding “Anterior Hip Dislocation 5 Months After Hip Arthroscopy”
To the Editor: I read with great interest the article “Anterior Hip Dislocation 5 Months After Hip Arthroscopy” by Austin et al.1 I would like to thank the authors for such an informative article. Being an amateur hip arthroscopy surgeon, it was an eye opener. I would be much obliged if the authors could answer a few questions I have. 1. How much of the capsule should be released, considering that we have to do the interportal capsular release and also the femoral neck capsular release since the authors stressed the importance of proper management of capsular release? Although we suture the capsule back before the skin closure, there is no proper information regarding the amount of capsular release.2 2. Since clinicoradiologically, the lesion was a cam lesion, can the excessive amount of femoral neck osteoplasty or resection be a cause of the patient’s anterior dislocation?3,4 3. Considering a female patient, what was her preoperative Beighton score? What are the chances that excessive ligament laxity might have been missed that would have been aggravated by the capsular release and femoral neck resection? I believe laxity can be one of the causes, considering the authors did not observe a capsular tear in the follow-up MRI. We close the capsule regularly in all our cases and believe it should be done without fail. Sarthak Patnaik, M.S.Ortho, F.S.S.I.S.A., F.A.S.M. Santander, Spain
Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.11.002
References 1. Austin DC, Horneff JG, Kelly JD. Anterior dislocation 5 months after hip arthroscopy. Arthroscopy 2014;30:1380-1382. 2. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br 2007;89:971-976. 3. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88: 925-935. 4. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404.
Author’s Reply To the Editor: I appreciate the inquiries by Dr. Patnaik and will attempt to answer them in sequence. 1. Regarding the volume of capsular release: In my opinion, the amount of capsular release should be just enough (but not more) to gain access to the femoral neck. The use of distraction portals and sutures can mitigate the need for complete iliofemoral ligament release. 2. Regarding cam resection as a source of instability: Theoretically cam resection does increase capsular laxity because it reduces the volume of intraarticular bone. Although excessive anterior neck resection can potentiate posterior subluxation in high hip flexion, I am not aware of any studies directly correlating bony cam resection alone with anterior instability. In our patient, I suspect the principle cause was anterior capsular laxity. 3. Regarding the issue of missed preoperative anterior instability: This question underscores the importance of more frequently recognized subtle anterior instability lesions of the hip, especially in female patients with ligamentous laxity. However, our patient did not display the characteristic straight anterior chondral wear pattern or direct anterior labral changes one would expect with anterior instability. Our patient showed the characteristic “wave sign” seen in cam impingement. I am grateful for Dr Patnaik’s questions and comments. Hip arthroscopists must be increasingly mindful of the role of instability, whether unrecognized or, as in this case, iatrogenic. More recent data suggest that better overall outcomes may be achieved with routine capsular closure.1
3.
4.
5.
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LETTERS TO THE EDITOR Library. LILACS. Available at: http://lilacs.bvsalud.org/en. Accessed October 2, 2014. Ejnisman L, Lipai RR, Cabrita HB, et al. Arthroscopic treatment of hip pathology in 35 athletes. Rev Bras Med 2011;68:6-10. Comba F, Buttaro M, Piccaluga F. Arthroscopic treatment of cam type femoroacetabular impingement of the hip: Surgical technique and initial results. Artrosc (B Aires) 2010;17:43-49. Mardones R, Tomic A, Vega R, Orrego M. Arthroscopic treatment of femoroacetabular impingement: Surgical technique and early results. Rev Argent Artroscop 2006;13:90-101. Polesello GC, Lima FR, Guimaraes RP, Ricioli W, Queiroz MC. Arthroscopic treatment of femoroacetabular impingement: Minimum five-year follow-up. Hip Int 2014;24:381-386.
Regarding “Anterior Hip Dislocation 5 Months After Hip Arthroscopy”
To the Editor: I read with great interest the article “Anterior Hip Dislocation 5 Months After Hip Arthroscopy” by Austin et al.1 I would like to thank the authors for such an informative article. Being an amateur hip arthroscopy surgeon, it was an eye opener. I would be much obliged if the authors could answer a few questions I have. 1. How much of the capsule should be released, considering that we have to do the interportal capsular release and also the femoral neck capsular release since the authors stressed the importance of proper management of capsular release? Although we suture the capsule back before the skin closure, there is no proper information regarding the amount of capsular release.2 2. Since clinicoradiologically, the lesion was a cam lesion, can the excessive amount of femoral neck osteoplasty or resection be a cause of the patient’s anterior dislocation?3,4 3. Considering a female patient, what was her preoperative Beighton score? What are the chances that excessive ligament laxity might have been missed that would have been aggravated by the capsular release and femoral neck resection? I believe laxity can be one of the causes, considering the authors did not observe a capsular tear in the follow-up MRI. We close the capsule regularly in all our cases and believe it should be done without fail. Sarthak Patnaik, M.S.Ortho, F.S.S.I.S.A., F.A.S.M. Santander, Spain
Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Ó 2015 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.11.002
References 1. Austin DC, Horneff JG, Kelly JD. Anterior dislocation 5 months after hip arthroscopy. Arthroscopy 2014;30:1380-1382. 2. Kampa RJ, Prasthofer A. The internervous safe zone for incision of the capsule of the hip. A cadaver study. J Bone Joint Surg Br 2007;89:971-976. 3. Espinosa N, Rothenfluh DA, Beck M, Ganz R, Leunig M. Treatment of femoro-acetabular impingement: Preliminary results of labral refixation. J Bone Joint Surg Am 2006;88: 925-935. 4. Matsuda DK. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25: 400-404.
Author’s Reply To the Editor: I appreciate the inquiries by Dr. Patnaik and will attempt to answer them in sequence. 1. Regarding the volume of capsular release: In my opinion, the amount of capsular release should be just enough (but not more) to gain access to the femoral neck. The use of distraction portals and sutures can mitigate the need for complete iliofemoral ligament release. 2. Regarding cam resection as a source of instability: Theoretically cam resection does increase capsular laxity because it reduces the volume of intraarticular bone. Although excessive anterior neck resection can potentiate posterior subluxation in high hip flexion, I am not aware of any studies directly correlating bony cam resection alone with anterior instability. In our patient, I suspect the principle cause was anterior capsular laxity. 3. Regarding the issue of missed preoperative anterior instability: This question underscores the importance of more frequently recognized subtle anterior instability lesions of the hip, especially in female patients with ligamentous laxity. However, our patient did not display the characteristic straight anterior chondral wear pattern or direct anterior labral changes one would expect with anterior instability. Our patient showed the characteristic “wave sign” seen in cam impingement. I am grateful for Dr Patnaik’s questions and comments. Hip arthroscopists must be increasingly mindful of the role of instability, whether unrecognized or, as in this case, iatrogenic. More recent data suggest that better overall outcomes may be achieved with routine capsular closure.1
