AANA Newsletter July 2025

A Stepwise Approach to the Failed Hip Arthroscopy

Andrea M. Spiker, M.D., FAANA
Member, AANA Communications and Technology Committee

 

The efficacy of hip arthroscopy has been supported by a growing body of literature demonstrating successful postoperative outcomes. Hip arthroscopy has also now been shown to be a true hip preservation surgery, with long-term follow-up demonstrating its protective effect against the development of osteoarthritis and need for a total hip replacement.1,2 These successful outcomes, of course, rely on appropriately diagnosing and indicating patients for surgery, appropriate imaging and physical exam examinations, and a technically well-executed hip arthroscopy surgery, utilizing evidence-based medicine and soft-tissue sparing and anatomic-restoring techniques.

 

Since hip arthroscopy’s introduction in the 1990s and early 2000s,3 the procedure itself has sprung onto the sports medicine scene in a flurry, with exponential growth over the years.4,5 With surgeons’ increasing interest in offering this procedure in their practices, along with the fact that hip arthroscopy has one of the highest learning curves of any orthopaedic surgery,6 we have naturally also seen an increase in the number of failed hip arthroscopy procedures.7

 

We have known for many years that one of the most common causes for a revision hip arthroscopy is residual cam impingement. Perhaps in response to this, over resection of the acetabulum and femoral neck has become a more common problem recently.8,9 As more surgeons have focused on the perfect bony resection, capsular violation and capsular defects have become more common complications. There are multiple documented patient factors, surgical factors and postoperative factors that have been shown to be correlated with failure. But when a patient with a failed hip arthroscopy presents in your office, what is the best way to go about diagnosing the problem and determining the best way forward? In my practice, I use a stepwise approach to the failed hip arthroscopy as described here.

 

First, we must define what failure is. In the broadest terms, a failed hip arthroscopy surgery would mean that the patient continued to have pain, had new pain after surgery or required a re-operation. But it is much more nuanced than this, and may be described by one of these following scenarios: 1) The patient had zero improvement after hip arthroscopy surgery; 2) the patient got better during protected weight-bearing but then pain returned thereafter; 3) the patient got better for an extended period of time and then re-injured themselves; 4) some pain got better, but not all of it or 5) preoperative pain got better but new pain developed after surgery.

 

When breaking down the definitions of failure, if the patient had zero improvement after hip arthroscopy surgery, we must question whether we had the correct diagnosis to begin with. With a high prevalence of asymptomatic labral tears,10 adjacent pain generators should be investigated, and we should weigh whether osteoarthritis might be worse than we thought. If the patient felt better during protected postoperative weight bearing, but then pain returned thereafter, we should consider whether the labrum or capsule didn’t heal, or whether the patient developed postoperative adhesions. If a patient did get better for an extended period of time and then re-injured him- or herself, we should carefully consider the bony morphology, including whether there is residual impingement, how much acetabular coverage or version is at play and whether excessive femoral version is at fault. If the patient has some pain that got better, but not all of it, we have to consider whether we forgot something such as an abductor tear or chondral flap. And finally, if preoperative pain got better, but then the patient developed new pain after surgery, we should consider postoperative adhesions, capsule dehiscence or even iatrogenic instability.

 

Then we have to categorize the type of failure in to either 1) a failure of surgical indications; 2) a failure of surgical technique; or 3) a failure of the patient postoperative healing/rehabilitation. Diagnostic evaluation in the failed hip arthroscopy in my practice involves repeat imaging, arthrogram along with an MR (whereas in a native hip I don’t use arthrogram dye), a low-dose 3D CT, and diagnostic injections when indicated. We also need to ensure that the patient has exhausted nonoperative management, including appropriate physical therapy and rehabilitation.

 

Together with the definition of failure, the category of failure, as well as additional diagnostic information, we can potentially come up with the reason the previous hip arthroscopy failed and thus come up with a solution for the patient. But we also have to recognize that in some cases, especially with the multiply-operated-on hip, we sometimes cannot figure out how to make the patient better. When surgery is not indicated, involving a multi-disciplinary team may be the best course for the patient.

 

Even with this stepwise approach, the answer is not always clear. The failed hip arthroscopy patient is a challenge and often requires significant time and careful evaluation. Phoning a friend in the hip arthroscopy world, consulting with colleagues and even referring the patient for a second opinion, is recommended and often necessary.

 

  1. Husen, M., Leland, D.P., Melugin, H.P., Poudel, K., Hevesi, M., Levy, B.A., Krych, A.J. Progression of Osteoarthritis at Long-term Follow-up in Patients Treated for Symptomatic Femoroacetabular Impingement With Hip Arthroscopy Compared With Nonsurgically Treated Patients. American Journal of Sports Medicine. 2023;51(11):2986-2995. doi:10.1177/03635465231188114
  2. Ramkumar, P.N., Olsen, R.J., Shaikh, H.J.F., Nawabi, D.H., Kelly, B.T. Modern Hip Arthroscopy for FAIS May Delay the Natural History of Osteoarthritis in 25% of Patients: A 12-Year Follow-up Analysis. American Journal of Sports Medicine. 2024;52(5):1137-1143. doi:10.1177/03635465241232154
  3. Kandil, A., Safran, M.R. Hip Arthroscopy: A Brief History. Clinics in Sports Medicine. 2016;35(3):321-329. doi:10.1016/J.CSM.2016.02.001
  4. Bonazza, N.A., Homcha, B., Liu, G., Leslie, D.L., Dhawan, A. Surgical Trends in Arthroscopic Hip Surgery Using a Large National Database. Arthroscopy. 2018;34(6):1825-1830. doi:10.1016/j.arthro.2018.01.022
  5. Cvetanovich, G.L., Chalmers, P.N., Levy, D.M., Mather, R.C., Harris, J.D., Bush-Joseph, C.A., Nho. S.J. Hip Arthroscopy Surgical Volume Trends and 30-Day Postoperative Complications. Arthroscopy. 2016;32(7):1286-1292. doi:10.1016/J.ARTHRO.2016.01.042
  6. Mehta, N., Chamberlin, P., Marx, R.G., Hidaka, C., Ge, Y., Nawabi, D.H., Lyman, S. Defining the Learning Curve for Hip Arthroscopy: A Threshold Analysis of the Volume-Outcomes Relationship. American Journal of Sports Medicine. 2018;46(6):1284-1293. doi:10.1177/0363546517749219
  7. 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. Arthroscopy. 2021;37(12):3445-3454.e1. doi:10.1016/J.ARTHRO.2021.04.017
  8. Shapira, J., Kyin, C., Go, C., Rosinsky, P.J., Maldonado, D.R., Lall, A.C., Domb, B.G. Indications and Outcomes of Secondary Hip Procedures After Failed Hip Arthroscopy: A Systematic Review. Arthroscopy. 2020;36(7):1992-2007. doi:10.1016/j.arthro.2020.02.028
  9. Ruzbarsky, J.J., Noorzad, A., Felan, N.A., Philippon, M.J. Revision Hip Arthroscopy Terrible Triad: Capsular Deficiency, Labral Deficiency, and Femoral Over-Resection. Arthroscopy. 2025;41(2):164-165. doi:10.1016/J.ARTHRO.2024.11.001,
  10. Tresch, F., Dietrich, T.J., Pfirrmann, C.W.A., Sutter, R. Hip MRI: Prevalence of Articular Cartilage Defects and Labral Tears in Asymptomatic Volunteers. A Comparison With a Matched Population of Patients With Femoroacetabular Impingement. Journal of Magnetic Resonance Imaging. 2017;46(2):440-451. doi:10.1002/JMRI.25565,
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