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We report a case of an iatrogenic bladder perforation sustained during laparoscopic lysis of adhesions performed for small bowel obstruction. The only sign, discovered by the anesthesiology team, was an inflated urinary catheter collection bag. This case revalidates the "catheter bag" sign and advocates for the placement of an indwelling transurethral urinary catheter before surgical incision in high-risk patients with previous pelvic and/or bladder pathology. In addition, vigilance from anesthesia providers and commitment to communication between anesthesia, surgical, and nursing care teams is emphasized to quickly discover complications and treat accordingly.

Background: Femoroacetabular impingement (FAI) is most commonly diagnosed in athletes who sustain repetitive flexion loading to their hips. No studies to date have focused solely on patients’ return-to-running ability after hip arthroscopy. Purpose: To evaluate patients’ ability to return to running after hip arthroscopy for FAI and capsular plication. Study Design: Case series; Level of evidence, 4. Methods: Clinical data were retrospectively retrieved for 51 consecutive patients with FAI (22 men, 29 women) who had undergone hip arthroscopy for the treatment of FAI and identified themselves as recreational or competitive runners on intake forms. Two-year outcome measures included the modified Harris Hip Score (mHHS) and the Hip Outcome Score Activities of Daily Living (HOS-ADL) and Sport-Specific (HOS-SS) subscales. A postoperative return-to-running survey was used to obtain running-specific information. Results: Patient age and body mass index (BMI) were a mean (±SD) of 26.3 ± 7.8 years and 23.7 ± 3.3 kg/m2, respectively. Before surgery, patients had refrained from running because of pain for a mean of 8.1 ± 5.7 months. After surgery, 48 patients (94%) returned to running at a mean of 8.5 ± 4.2 months. Patients who had discontinued running for more than 8 months before surgery had a longer return-to-running time than did those who had stopped for less than 8 months (10.6 ± 4.2 vs 7.6 ± 4.1 months; P = .01). After 2 years, mean preoperative distance had decreased significantly ( P < .01) from 9.5 ± 6.5 miles per week when healthy to 6.4 ± 5.8 miles postoperatively. Despite decreased mileage, all 2-year outcomes scores improved significantly ( P < .001). Conclusion: Recreational and competitive runners with FAI returned to running 94% of the time at a mean of 8.5 months after hip arthroscopy. However, runners should be counseled before their surgery that they may run fewer miles than when they were pain free. Additionally, patients with a higher BMI and/or longer preoperative lull may have a longer recovery time.

In addition to trochanteric bursitis, gluteus medius and minimus tears (GMMTs) can be a common source of insidious lateral hip pain and dysfunction. Partial-thickness GMMTs are much more common than full-thickness GMMTs but are frequently overlooked by both radiologists and orthopaedic surgeons. GMMTs are commonly identified on magnetic resonance imaging ordered for lateral hip pain unresponsive to conservative management. Imaging can show that high-grade partial articular gluteus tendon avulsion (PAGTA) can occur as either an isolated gluteus medius tear, an isolated gluteus minimus tear, or a combined GMMT. We describe how to identify PAGTA injuries with intraoperative assessment and identification of the interval between the gluteus medius and minimus tendons to allow access to the PAGTA without violating the bursal side of the tendon. PAGTAs can be repaired arthroscopically by single- or double-row suture anchor fixation depending on the size of the tear. The purpose of this article is to guide orthopaedic surgeons in the recognition of PAGTA with magnetic resonance imaging and dynamic examination to allow for accurate repair of GMMTs.

The most commonly reported reasons for persistent hip pain after hip arthroscopy are residual femoroacetabular impingement, dysplasia and dysplasia variants, or extra-articular impingement. There are some cases in which the underlying osseous pathomorphology has been appropriately treated, and the cause of persistent hip pain can be soft-tissue injuries such as chondrolabral tears or capsular abnormalities. Capsular defects after hip arthroscopy may suggest an alteration of the biomechanical properties of the iliofemoral ligament and lead to iatrogenically induced hip instability. There are a growing number of biomechanical and clinical studies showing the importance of capsular management during hip arthroscopy. We describe the workup, examination under anesthesia, diagnostic arthroscopy, and technique of capsular plication for iatrogenic instability of the hip.

Atraumatic hip instability is a recently described source of hip pain and disability. Hip instability may be caused by bony dysplasia, benign or inherited joint hypermobility syndromes, or iatrogenic damage to the hip capsule during arthroscopy. A thorough understanding of hip capsular anatomy is essential to the management of instability, and is reviewed in this study. In addition, the essential historical, clinical, and radiographic findings of atraumatic hip instability are presented. Critical concepts include early referral in the presence of inherited joint hypermobility syndromes, the use of validated criteria for detection of benign joint hypermobility, and systematic efforts to understand the cause of instability before initiating treatment. Although nonoperative measures can successfully treat atraumatic hip instability, surgical intervention is often warranted, and the technical principles of hip capsular plication are described in detail.

To compare the return-to-play rates, patient-reported outcome (PRO) scores, and satisfaction between high-level amateur athletes and recreational athletes and to evaluate for differences in ability to return to sport in these groups based on patient-related and sport-related characteristics.Clinical data were retrieved for 66 (26 male/40 female) consecutive athletes undergoing hip arthroscopy for femoroacetabular impingement. Athletes were classified as high-level amateur or recreational. Athletes were also divided into 6 distinct sporting categories based on the physical demands on the hip. Preoperative and 2-year PROs including a sport-specific questionnaire, modified Harris Hip Score (MHHS), and Hip Outcome Scores with Activities of Daily Living (HOS-ADL) and Sports-Specific (HOS-SS) subscales were collected.Of the 66 patients, 49 were recreational and 17 were high-level amateur athletes (10 high school and 7 collegiate). High-level athletes were significantly younger than recreational athletes (18.4 ± 2.3 years vs 29.7 ± 6.8 years; P.001). After 2 years, all PROs had improved significantly, with no differences between the 2 athletic groups. There was a high overall rate of return for both recreational and high-level amateur athletes (94% vs 88%; P = .60). Increasing preoperative withdrawal time from sport prior to surgery was associated with decreased HOS-SS (r = 0.33; P = .04) and MHHS scores (r = 0.02; P = .02). Overall, athletes who had withdrawn from sport for greater than 8 months before surgery returned to sport significantly more slowly (P = .01). Increasing body mass index (BMI) was associated with lower improvements in HOS (r = 0.26; P = .04) and MHHS scores (r = 0.38; P.01).Recreational athletes, despite being significantly older than their high-level counterparts, return to play at a similar high rate and with comparable PROs. Increasing preoperative cessation time from sport significantly prolongs return to sport. Additionally, increasing preoperative cessation from sport and higher preoperative BMI were associated with decreased improvements in PROs.Level III, retrospective comparative study.

Context Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy. Objectives (1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, (2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols, and (3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy. Data sources Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched. Study selection Level I–IV evidence clinical studies with minimum 2-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included. Data extraction All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the modified Coleman methodology score. Results Eighteen studies were included (2,092 subjects; 52% male, mean age 35.1 ± 10.6 years, mean follow-up 3.2 ± 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return to sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported. Conclusion The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. Strengths and limitations in the literature were identified. Future studies should recognize and report the essentials of rehabilitation following hip arthroscopy.

Objectives: The use of hip arthroscopy has increased over recent years to treat various forms of hip pathologies including femoroacetabular impingement. While a capsulotomy facilitates adequate visualization and access for diagnostic and interventional purposes, the current literature remains divided over the use of routine capsular closure to address the iatrogenic instability that may be induced by an excessive or unclosed capsulotomy. The purpose of this biomechanical study was to determine if hip capsulotomy creates significant alterations in rotational range of motion and stability measures. Additionally, does a capsular repair return these variables to normal? Methods: Eight fresh-frozen cadaveric hip specimens consisting of the hemipelvis, femur, and overlying soft tissues were used for this study. All specimens were screened by computed tomography (CT) to assess for the absence of significant bony pathology. Each hip was then tested under torsional loads of 6 N·m applied via a pulley system in conjunction with a vertical force exerted by a servohydraulic frame. Conditions tested were as follows: 1) neutral flexion with the capsule intact 2) neutral flexion with a 4 cm inter-portal capsulotomy 3) neutral flexion with a 6 cm inter-portal capsulotomy 4) neutral flexion with capsulotomy repair. Soft tissue was retained during all interventions. Range of motion (from external to internal rotation), hysteresis area, and neutral zones were the outcome measures for stability obtained in each condition. Results: While the data demonstrated a positive and statistically significant correlation between the sizes of the capsulotomy and measures of joint instability (range of motion (ROM), hysteresis area, and neutral zone), no significant differences were seen between the intact and repaired hips with regards to such measures (Table). Larger size capsulotomies were accompanied by significant increases in all three measures of joint instability while the repair effectively restored the capsule to conditions similar to its intact state. Conclusion: To the best of the authors’ knowledge, this study is the first to demonstrate the biomechanical consequences of sequentially increasing capsulotomy incisions and their repair on a hip joint that still contains its surrounding soft tissue. The results of this study not only confirm the notion of introducing iatrogenic joint instability with larger sized capsulotomies, but also propose the complete capsular closure as an appropriate solution.