MINI REVIEW

published: 05 July 2021

doi: 10.3389/fsurg.2021.662720

Revision Hip Arthroscopy in the

Native Hip: A Review of
Contemporary Evaluation and
Treatment Options
Kyle N. Kunze, Reena J. Olsen, Spencer W. Sullivan* and Benedict U. Nwachukwu
Hospital for Special Surgery, New York, NY, United States

Hip arthroscopy is a reproducible and efficacious procedure for the treatment of

femoroacetabular impingement syndrome (FAIS). Despite this efficacy, clinical failures
are observed, clinical entities are challenging to treat, and revision hip arthroscopy may
be required. The most common cause of symptom recurrence after a hip arthroscopy
that leads to a revision arthroscopy is residual cam morphology as a result of inadequate
femoral osteochondroplasty and restoration of head–neck offset, though several other
revision etiologies including progressive chondral and labral pathologies also exist.
In these cases, it is imperative to perform a comprehensive examination to identify
the cause of a failed primary arthroscopy as to assess whether or not a revision
Edited by: hip arthroscopy procedure is indicated. When a secondary procedure is indicated,
Edward Charles Beck,
approaches may consist of revision labral repair, complete labral reconstruction, or labral
Wake Forest Baptist Medical Center,
United States augmentation depending on labral integrity. Gross instability or imaging-based evidence
Reviewed by: of microinstability may necessitate capsular augmentation or plication. If residual cam
James Wylie, or pincer morphology is present, additional resection of the osseous abnormalities
Intermountain Healthcare,
United States may be warranted. This review article discusses indications, the evaluation of patients
Claudia Di Bella, with residual symptoms after primary hip arthroscopy, and the evaluation of outcomes
The University of Melbourne, Australia
following revision hip arthroscopy through an evidence-based discussion. We also
*Correspondence:
present a case example of a revision hip arthroscopy procedure to highlight necessary
Spencer W. Sullivan
spencer.sullivan44@gmail.com intraoperative techniques during a revision hip arthroscopy.
Keywords: hip preservation, femoroacetabular impingement, clinical failure, revision arthroscopy, arthroplasty,
Specialty section:
outcomes
This article was submitted to
Orthopedic Surgery,
a section of the journal
Frontiers in Surgery
INTRODUCTION/BACKGROUND
Received: 01 February 2021 The prevalence of hip arthroscopy has increased as techniques for identifying and treating
Accepted: 03 June 2021 femoroacetabular impingement (FAI) continue to improve. This condition describes the abnormal
Published: 05 July 2021
contact of the femoral head–neck junction with the acetabulum and labral complex due to
Citation: bony morphological abnormalities in the femoral head and/or acetabulum (1). Although widely
Kunze KN, Olsen RJ, Sullivan SW and
successful with an overall low complication rate (4%), the clinical outcome is sometimes
Nwachukwu BU (2021) Revision Hip
Arthroscopy in the Native Hip: A
unsatisfactory (2). As the incidence of hip arthroscopy procedures performed annually continues to
Review of Contemporary Evaluation grow, so too does the incidence of patients who will require re-intervention and possible revision
and Treatment Options. surgery. Therefore, it is imperative that hip arthroscopists must understand the presentation of
Front. Surg. 8:662720. patients with a failed hip arthroscopy and the etiologies of failure in order to identify such patients
doi: 10.3389/fsurg.2021.662720 and treat them efficaciously.

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Kunze et al. Revision Hip Arthroscopy Review

The leading cause of clinical failure in hip arthroscopy is arthroscopy. Another common cause of symptomatic recurrence
persistent FAI secondary to residual cam morphology, which is microinstability of the hip capsule, though patients may
may be combined with high-grade chondral damage and labral also experience instability in the setting of cam over-resection
pathology (3, 4). Studies have estimated the average amount of and loss of the hip suction seal. Other etiologies that may
time to be between 18 and 25.6 months between primary and necessitate revision hip arthroscopy include chondral wear, labral
revision surgeries (5, 6). Other etiologies of a failed primary hip tears and calcifications, synovitis, adhesions, loose bodies, and
arthroscopy include microinstability of the hip capsule, labral instability (3, 4, 9). Full-thickness acetabular articular cartilage
degeneration or re-tears, and progression to more severe grades defect (FAACD) is chondral delamination that can cause pain
of osteoarthritis, though other more rare etiologies exist. Revision and a catching sensation and, if left unaddressed during the
candidates commonly present with missed or undertreated FAI, index procedure, can contribute to loose bodies and progression
however, at varying rates. Philippon et al. (7) report the incidence of osteoarthritis (12). Open surgery may be required to address
of residual FAI in revision cases to be 95%, which is often a instability, dysplasia, or extra-articular impingement of the
result of under-resection and over-resection leading to residual greater trochanter or subspine (9).
impingement or instability and leading to persistent or recurring Evaluation of the patient must be thorough to properly guide
symptoms postoperatively (8). Therefore, it is important to surgical decision-making. Importantly, another mechanism of
identify and fully treat FAI during the initial hip arthroscopy. failure consists of advanced cartilage pathology. Though patients
Furthermore, it is important to identify the common failure may present with symptoms mimicking that they experienced
mechanisms and to understand how to address them with prior to their index procedure, patient selection is a crucial aspect
secondary procedures. in this setting as more advanced stages of osteoarthritis should be
The decision algorithm for revision hip arthroscopy can be treated with hip arthroplasty as to avoid a second failure (13).
complex and is affected by a wide range of factors. Current Therefore, a thorough understanding of the causes of the failed
indications for revision arthroscopy and associated outcomes primary hip arthroscopy and which patients are appropriate
remain unclear and are a focus of this research study. The candidates for a revision procedure is a key component of
purpose of this study is to synthesize indications for revision successful treatment.
hip arthroscopy following a failed primary arthroscopy using
evidence to support these indications when available. Next,
we describe the preferred surgical technique of the authors CLINICAL EVALUATION
for a case of revision hip arthroscopy and then describe the
other surgical approaches that exist. Finally, we will use an All patients with symptom recurrence warrant a thorough
evidence-based discussion to describe the outcomes of revision clinical examination in the postoperative setting. A thorough
hip arthroscopy. This information can facilitate preoperative history may help the surgeon narrow the differential diagnosis.
discussion and planning between patients and their surgeons and Pain is present in almost all patients and, therefore, non-specific;
can guide the expectations of patients about the procedure. however, it is useful to prompt investigation into the underlying
etiology as it may indicate labral re-tear. Infection should always
be ruled out in this setting despite low likelihood, and the
PREDICTORS, ETIOLOGIES, AND surgeon should order tests for complete blood count, erythrocyte
INDICATIONS FOR REPEAT HIP sedimentation rate, and C-reactive protein. In patients with
ARTHROSCOPY concomitant musculoskeletal pathologies, it is important to
determine whether this pain is referred from the spine or
Ricciardi et al. (9) found that patients undergoing revision is a result of intra-articular or extra-articular hip pathology.
surgery were typically younger and female. Another study by Patients with instability secondary to microinstability or previous
West et al. (5) also confirmed younger age (<50 years) as a capsulotomy without closure may report subluxation events
predictor of revision but did not see a significant difference in where they believe their hip is “coming out of their socket”
revision rates when looking at the gender of the patients. Some or have apprehension with certain movements that stress the
observed factors associated with revision are increased acetabular iliofemoral ligament. Hip dysplasia, femoral anteversion >40◦ ,
coverage (lateral center edge angle, LCEA, >33◦ ), pistol grip/cam connective tissue disorders, and previous traumatic hip injuries
deformity before a primary arthroscopy, and unresolved high predispose individuals to post-arthroscopic hip instability (14).
pistol grip deformity (10). Additionally, Shah et al. (11) identified As most etiologies cause pain around the hip joint, physical
predictors of failed arthroscopy necessitating revision, including examination and diagnostic imaging are crucial components of
small LCEA (moderate to severe hip dysplasia), larger Tonnis the evaluation.
angle, ≤2 mm joint space, and a broken Shenton line. Inspection of the previous portal incisions should be
There is a wide range of etiologies that may necessitate a performed to rule out wound complications as this may
revision hip arthroscopy that results in persistent symptoms point the surgeon to surgical site infection as the etiology of
and dysfunction (Table 1). Despite the etiology, the primary hip pain. Palpation of the pubic tubercle, greater trochanter,
indication for revision hip arthroscopy is symptom recurrence. anterior superior iliac spine, and sacroiliac joints should be
Residual FAI secondary to inadequate cam resection during the performed as these may point toward core muscle injury,
index procedure is the most common finding of a failed hip bursitis, or other tendinopathies as the pain generator. Range

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Kunze et al. Revision Hip Arthroscopy Review

TABLE 1 | Indications for revision hip arthroscopy.

Recurrent symptoms (hip pain, subjective instability, and dysfunction) reproducible on physical examination with at least ONE of the following:

- Alpha angle on AP or Dunn lateral 360 degrees or over-resection of more than 5% of the diameter of the femoral head on the Dunn view.
- Evidence of femoral head lucencies concerning for avascular necrosis
- Identifiable loose bodies on any imaging modality
- Evidence of labral calcification ± labral tear or fraying
- Any labral re-tear
- Subspine impingement
- Focal femoral head or acetabular chondral defects amenable to repair without Tonnis grade >1
- MRA evidence of capsular defects or laxity

of motion examination should be performed and compared percentage of revision cases that are not primarily due to residual
with the opposite limb. A positive impingement sign can be bony abnormalities. As such, capsular insufficiency should be
clinically evaluated by performing the anterior impingement considered when a patient presents with residual hip pain in the
test by moving the hip in flexion, adduction, and internal absence of obvious residual FAI.
rotation (FADIR) (15). Though rare, coxa saltans internal or An intra-articular hip steroid injection can be particularly
external type may be identified with an audible snapping important to confirm the surgical indication. A positive response
during the range of motion of the hip. Coxa saltans internal to an intra-articular hip steroid injection is important for
snapping is reproduced by passively moving the hip from confirming the intra-articular nature of the problem. In patients
a flexed and externally rotated position to an extended and with imaging and clinical examinations, pointing toward the
internally rotated position. Patients with iatrogenic hip capsule need for revision surgery, but with a negative response to an
instability may also demonstrate positive findings on axial intra-articular injection consideration of extra-articular sources
distraction testing (16). of pain, should be considered. In particular, extra-articular sub-
Repeat imaging of the symptomatic hip following a failed spine impingement, psoas tendinitis, lumbar spine pathology,
primary hip arthroscopic procedure is essential to understand and pelvic floor pain are often complicating diagnoses in
the etiology. Imaging options to be used include anterior– patients with persistent pain after primary hip arthroscopy. The
posterior (AP) pelvis, false profile, and frog-leg or Dunn lateral surgeon should have a lower threshold to perform revision hip
radiographs, CT scans with or without three-dimensional (3D) arthroscopy in an expeditious manner when symptom recurrence
reconstruction, and MRI. Plain radiographs of standing AP pelvis in conjunction with positive imaging findings of a treatable
and Dunn view with 45◦ hip flexion can be used to identify etiology is present as to not predispose the patient to additional
residual cam and pincer impingement in addition to over- morbidity and joint degeneration.
resection (1, 17). We do not believe that radiographic or CT
evidence of borderline hip dysplasia should be a contraindication
to revision hip arthroscopy as good outcomes have been reported SURGICAL TECHNIQUES
in these populations (18, 19). CT imaging is suggested for
The surgical preparation and hip arthroscopy setup are largely
assessing the abnormalities of acetabular and femoral versions
identical in all cases of revision hip arthroscopy. The major
that may contribute to the range of motion or impingement
difference in revision hip arthroscopy is the procedures to be
abnormalities, though this is not commonly obtained (17). A
performed based on the history and clinical examination of
more useful application of CT in the revision setting is 3D
the patient. The proceeding section briefly describes procedures
reconstruction, which allows the surgeon to better plan their
commonly performed in revision hip arthroscopy.
degree of chondroplasty in revision settings. The use of MRI
may help identify labral re-tears, chondral damage, avascular
necrosis, or stress fracture. This is especially important in the Labral Repair, Augmentation, and
setting of labral re-tears that are irreparable due to calcification Reconstruction
or lack of sufficient labrum with sufficient integrity as the Labral repair is indicated during revision hip arthroscopy when
surgeon may plan a labral reconstruction or augmentation for the a patient presents with pain, and there is MRI evidence of a
revision. MR arthrogram (MRA) can be beneficial for visualizing labral repair with sufficient tissues to repair. Debridement in
the integrity of the hip capsule (20, 21). MRA evidence of the revision setting is uncommon as damaged tissues or re-tears
capsular defects and instability on T1-weighted images include are often not amenable to this treatment due to the quality of
capsular scarring or capsular contraction, (2) anterior iliofemoral the tissue. In cases where the labrum is torn but is irreparable
attrition or partial healing, (3) anterior iliofemoral separation and secondary to insufficient remaining tissue or tear size, a labral
retraction, or (4) extracapsular dye extravasation due to gluteus augmentation or complete reconstruction can be performed
minimus or gross capsular incompetency (21). McCormick et al. (22). Labral reconstruction can be segmental or circumferential
(21) suggest that capsular deficiency may be present in a high depending on the extent and quality of labral degeneration. A

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Kunze et al. Revision Hip Arthroscopy Review

tensor fascia lata allograft was first described to augment or after primary hip arthroscopy, we do not recommend performing
reconstruct the labrum (23), though several graft options have these procedures in conjunction with revision hip arthroscopy
since been used with good to excellent outcomes (24–26). We for intra-articular or capsular etiologies.
recommend the use of labral repair in the revision setting if the
labrum is deemed reparable as we argue that this disrupts the OUTCOMES
anatomy and suction seal of the patient to a lesser extent than
alternatives. A low threshold should be maintained to reconstruct Research studies on outcomes and efficacy following revision
the labrum if there is doubt as to the quality of remaining labral hip arthroscopy are growing but are limited (3, 34, 35). Recent
tissue. There is little evidence available as to whether a particular studies do show significant improvement in patient-reported
graft type is superior. outcome (PRO) following revision hip arthroscopy (34, 36). A
meta-analysis by O’Connor et al. (37) reported a significant
Osteochondroplasty and Trimming for improvement in all PRO scores from before operation to the
Residual Osseous Deformities latest follow-up after revision, with the greatest average increase
Acetabular rim trimming may be implicated for residual shown in the modified Harris Hip Score (mHHS) (+17.20) and
pincer morphology, while additional femoral osteochondroplasty the Hip Outcome Score–Activities of Daily Living (HOS-ADL)
may be implicated in the patient with symptom recurrence (+13.98), and a decrease in the visual analog scale for pain (VAS)
and evidence of residual cam morphology. It is imperative (−3.16). Domb et al. (34) reported similar results from a study
that preoperative radiographic indices of cam morphological of 47 revision hip arthroscopies at a mean length of follow-up of
dimensions can be made in order for the hip arthroscopist 29 months, concluding a statistically significant improvement in
to appropriately plan the depth and extent of their resection, each PRO measured: mHHS, HOS-ADL, HOS Sports Subscale
as over-resection can lead to instability and inferior outcomes (HOS-SS), VAS for pain, and the Non-arthritic Hip Score
as noted. These procedures are performed through the same (NAHS). Positive pre-operative predictors for improvement in
approach and portals as used in a primary hip arthroscopy PROs are previous open surgery, FAI, symptomatic heterotopic
procedure. Intraoperative examination of the cartilaginous ossification, and segmental labral defects (34). A pair-matched
components of the femoral head and acetabular should be study comparing clinical outcomes after labral reconstruction
performed regardless of whether there is evidence of chondral vs. labral repair during revision arthroscopy was carried out
lesions or delamination on preoperative imaging. If identified, by Perets et al. (38) and showed similar clinical improvement
focal chondral lesions can be addressed with microfracture, postoperatively and comparable complication rates. The authors
matrix-enhanced chondral implantation (27), or autologous concluded that both procedures are safe and effective labral repair
chondrocyte implantation (28, 29). Though some studies have treatment options during revision arthroscopy (38).
investigated the use of bone marrow aspirate concentration, Despite many studies reporting statistically significant
platelet-rich plasma, and mesenchymal stem cells, the current improvement in all clinical outcomes following revision
evidence is of low quality (30). hip arthroscopy surgery, these outcomes tend to be inferior
when compared to patient outcomes following primary hip
Capsular Management arthroscopy (17, 35). Larson et al. (35) matched cohorts of
Though we recommend complete capsular closure in all primary primary and revision arthroscopies and reported a significantly
and revision hip arthroscopy cases, patients in whom the capsule larger improvement in PROs for primary surgery patients in
was not closed or who have capsular and generalized ligamentous mHHS and VAS scores. It has been shown that after revision,
laxity should undergo complete capsular closure and/or plication. improved PROs, high survivorship, and patient satisfaction
During revision hip arthroscopy, it is beneficial to establish are present at 2-year short-term clinical follow-up (36).
identical portals in order to access the areas in which the Although research studies have shown that some positive
capsule was previously violated in order to be able to successfully results (outcome scores) following revision surgery have been
close them (i.e., the interportal capsulotomy sites). In patients reported to be less durable as compared to those following a
with iatrogenic hip instability and without evidence of residual primary arthroscopy, decreases in mHHS, satisfaction, HOS-
osseous abnormalities, it is appropriate to perform revision hip ADL, and HOS-SS have been seen near the 3-year follow-up
arthroscopy for capsular repair (16, 31). mark (34, 39).
Nwachukwu et al. (40) described values of minimal clinically
Extra-Articular Pathology important difference (MCID) and substantial clinical benefit
Snapping hip syndrome is infrequently an indication for revision (SCB) for patients undergoing revision hip arthroscopy to define
hip arthroscopy, though patients may present with this pathology meaningful improvement in outcomes. MCID is the smallest
in conjunction with those described above. A recent study has change in the outcome that can be appreciated by the patient,
described the use of an endoscopic iliotibial band release during while SCB is a considerable change that a patient perceives as a
hip arthroscopy for FAIS and coxa sultans external type with substantial improvement. Considered, respectively, as the floor
good short-term outcomes (32). There is a paucity of studies and upper threshold for clinical success, MCID and SCB values
on iliopsoas tenotomy during hip arthroscopy, with reports of identified in this study on mHHS, HOS ADL, HOS-SS, and the
previous studies demonstrating that performing this additional international Hip Outcome Tool-33 (iHOT-33) were comparable
procedure may predispose patients to inferior outcomes (33). As to those values already defined for primary hip arthroscopy.
these studies have demonstrated the potential for worse outcomes Therefore, despite previously reported research studies showing

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Kunze et al. Revision Hip Arthroscopy Review

that revision patients tend to report lower PROs than a CONCLUSIONS

primary arthroscopy cohort, when accounting for clinically
meaningful improvement, these cohorts achieve comparable The leading cause of failure after primary hip arthroscopy leading
improvement in clinically significant outcomes. Additionally, to revision hip arthroscopy is residual cam morphology and
revision patients presenting with residual impingement achieved symptom recurrence. The currently available studies suggest
MCID at a higher rate than patients with diagnoses other that patients undergoing revision hip arthroscopy can achieve
than FAI (40). good outcomes if indicated appropriately. Therefore, a thorough
In some cases, patients may need a repeat revision hip clinical examination and advanced imaging are imperative. Care
surgery, i.e., a third hip arthroscopy. Despite the available studies should be taken to evaluate for chondral pathology and capsular
demonstrating improvements in PROs and high survivorship incompetency in this setting. Failure to address these findings
after revision hip arthroscopy, there is a body of evidence may result in inferior outcomes. The surgical technique should
reporting on second revision hip arthroscopy and conversion to be tailored to the underlying cause for revision arthroscopy.
hip arthroplasty (3, 6). In a comprehensive systematic review Continued improvements in hip arthroscopy techniques and
by Cvetanovich et al. (3), these reoperations occurred at an understanding of risk factors for failure will likely diminish the
overall rate of 5% after an average of 14.9 months following a incidence of revision cases. This review article can be used to
revision arthroscopy and up to 14.6% in the studies (6). Patients inform and guide identification, treatment, surgical decision-
presenting with narrowing joint space and chondral damage making, and expected outcomes of patients indicated for revision
during the evaluation of recurring symptoms after a primary hip arthroscopy.
arthroscopy are reported to have less improved outcomes and
a greater likelihood of undergoing total hip arthroplasty (THA) AUTHOR CONTRIBUTIONS
following a revision (3). Mansor et al. (1) reported that cam
over-resection on the Dunn view, that is >5% of the femoral SS, RO, and BN contributed to conception and design of the
head diameter, led to worse clinical outcomes following revision study. RO, SS, and KK conducted literature reviews and data
arthroscopy and lower survivorship with greater reports of analysis. RO wrote the first draft of the manuscript. KK, SS, and
conversion to THA. Due to the paucity of studies in reoperation BN wrote sections of the manuscript. KK performed all major
rates following revision hip arthroscopy, research studies are revisions of the final manuscript and additional literature review
limited in comparing patient outcomes of second revision necessary for publication. All authors contributed to manuscript
surgery and primary THA. revision, read, and approved the submitted version.

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associated with femoroacetabular impingement treated by autologous matrix- of the scope of the submitted manuscript.
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follow-up. Arthroscopy. (2018) 34:3012–23. doi: 10.1016/j.arthro.2018.05.035 The remaining authors declare that the research was conducted in the absence of
30. Robinson PG, Murray IR, Maempel J, Rankin CS, Hamilton D, Gaston P. Use any commercial or financial relationships that could be construed as a potential
of biologics as an adjunct therapy to arthroscopic surgery for the treatment conflict of interest.
of femoroacetabular impingement: a systematic review. Orthop J Sports Med.
(2019) 7:2325967119890673. doi: 10.1177/2325967119890673 Copyright © 2021 Kunze, Olsen, Sullivan and Nwachukwu. This is an open-access
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al. Two-year patient-reported outcomes for patients undergoing revision BY). The use, distribution or reproduction in other forums is permitted, provided
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36. doi: 10.1016/j.arthro.2019.07.026 publication in this journal is cited, in accordance with accepted academic practice.
32. Zhang S, Dong C, Li Z, Wang Z, Wei M, Tong P, et al. Endoscopic No use, distribution or reproduction is permitted which does not comply with these
iliotibial band release during hip arthroscopy for femoroacetabular terms.

Frontiers in Surgery | www.frontiersin.org 6 July 2021 | Volume 8 | Article 662720