Complications
Nothing in life is ever as straightforward as one might wish. Fortunately complications associated with hip arthroscopy are few, affecting only 1.6% of patients. In the entire Cambridge series (now over 1000 cases) no complication has been permanent.
General complications, common to all operations, obviously apply here and will not be tabulated. However, complications specific to hip arthroscopy can occur under the following headings:
- Neurological
- Vascular
- Infective
- Inflammatory
- Cutaneous
- Symptomatic
- Articular
- Technical
Neurological
The following nerves can be damaged:
- Femoral
- Sciatic
- Lateral cutaneous nerve of thigh
- Pudendal
Nerve damage can be minimised by reducing traction time, with judicious use of the trial of traction. Pudendal nerve palsy, leading to impotence, has not been seen in the Cambridge series, though has been reported elsewhere. It may be due to pressure from the perineal bollard. This area should therefore be padded thoroughly at surgery. Not all nerve damage is permanent. The only femoral nerve `palsy' seen in the Cambridge series was actually due to the intra-articular bupivacaine used at the end of the procedure and had recovered fully within six hours of surgery.
Vascular
Vascular complications are uncommon. They can be classified as follows:
- Post-operative haemorrhage
- Major vessel damage
Haemorrhage at surgery is an obvious problem that can normally be overcome by using a fluid management system. Postoperative haemorrhage, through the stab portals, can sometimes be seen. Should this occur the patient should not be mobilised, but left in bed, affected side uppermost with pressure applied, until bleeding stops. The source is usually a subcutaneous vessel. This complication is normally seen in the obese.
Major vessel damage has not been seen in the Cambridge series, though the supratrochanteric approach is used for almost all cases. Sometimes the foot can turn bluish during the operation, particularly if traction is prolonged. Ignore this, provided that surgery is taking no more than 30-40 minutes, as the appearance will recover as soon as traction is released.
Infective
In common with other forms of arthroscopy, infection after hip arthroscopy is extremely rare. One case has been seen in the Cambridge series. No antibiotic cover is used.
Inflammatory
The only complication in this category is trochanteric bursitis. In a small percentage of patients pain and swelling can occur over the greater trochanter. This may be due to deeper bleeding, or may be a genuine bursitis. Whatever the cause, a conservative approach has been universally successful.
Cutaneous
These can be as follows:
- Keloid scar formation
- Perineal splitting
- Pressure sores
Only stab incisions are used for hip arthroscopy, so keloid formation is, perhaps, an academic issue. However, it can be seen though is rarely a problem. Perineal splitting is an issue. Exclusive to girls, it can occur during lateral displacement of the hip by the perineal bollard. The posterior commissure (the area between vagina and anus) can split. This region should be watched like a hawk during patient positioning. Once the operation is underway perineal splitting is no longer a problem. Pressure sores must be avoided by use of judicious padding of the traction table or distracter. Male genitalia in particular must not be caught between perineal bollard and thigh!
Symptomatic
It is unusual for a patient to be made worse after hip arthroscopy. However if arthroscopic debridement is undertaken for osteoarthritis up to 5% of patients can be made worse. They should be warned beforehand. In practice this is only really an issue if the osteoarthritis is severe and the patient over approximately 45 years of age.
Articular
Scuffing of the articular surfaces, particularly the femoral head, can occur. Proper use of a guide wire can minimise this. It is possible for the surgeon to `feel' the tip of the trocar as it enters the joint. There is a great difference between the resistance encountered from a tight capsule, and that due to an articular surface. Take a different track if the trocar abuts the femoral head. Scuff damage is not exclusive to hip arthroscopy, as any arthroscopic surgeon will vouch. Whether or not there are any long term consequences to the patient is not known, but it makes sense to keep articular damage to a minimum.
Technical
It may not be possible to gain access to the hip at all! The patient should be so warned and the surgeon should be prepared to abandon the procedure if too much difficulty is encountered