Postarthroscopic iatrogenic FAI-like hip syndrome.

To the Editor: While reviewing cases for arbitration or malpractice, I encountered an interesting case where an anterior small labrum tear was converted through arthroscopic surgery into an entity called femoroacetabular impingement–like syndrome. A 36-year-old woman underwent a Ludlow procedure during infancy for developmental dysplasia of the right hip following 2 weeks of Bryant traction. She conducted a normal life until 4 months ago, when she reported right knee, groin, and thigh pain during activities of daily living. Hip range of motion was limited by pain in flexion, abduction, and external rotation. Radiographs showed a well-developed right hip joint, and magnetic resonance arthrogram showed a small anterior labrum tear, which, according to her surgeon, explained her pain. She underwent surgical arthroscopy combined with an iliopsoas tenotomy to repair the tear. Intraoperatively, she underwent anchor fixation of the labrum tear and anterior capsule resection followed by tenotomy of the iliopsoas. However, following exploration of the joint, the surgeon performed 2 more procedures despite having no correlation with the clinical presentation and diagnosis. He noted a minor protuberance at the anterolateral head–neck junction and performed a formal osteoplasty of that area. He noted the old stump of the ligamentum teres from the Ludlow procedure, interpreted it as a rupture of the ligament, and performed a formal debridement. Following 1 month of complete rest and after returning to activities such as taking short walks, the patient presented with excruciating pain radiating from the groin and buttock along the entire right leg. The pain was reproduced by hip flexion, adduction, and internal rotation. The role of possible lumbar radicular syndrome was ruled out clinically and by computed tomography. Infiltration of the hip joint with bupivicaine temporarily alleviated all pain. Repeat magnetic resonance arthrogram showed 2 inflicted iatrogenic injuries: the bony crater created at the head– neck junction and a substantial tear of the posterior labrum. The anterolateral bony crater was regarded as causing the femoroacetabular impingement–like syndrome of groin pain when impinging against the acetabular rim in flexion, adduction, and internal rotation of the hip (Figure). The pain radiating from her buttock and alleviated by bupivicaine infiltration of the joint was evidently due to the long tear of the posterior labrum. The patient entered the procedure with a small anterior labrum tear syndrome and ended with 2 other painful syndromes. I refer to this case to emphasize an attitude that has been known for years. Any time that arthroscopic surgery of a certain joint becomes popular, a variety of modifications and improvisations are undertaken with the intention to improve the surgical result and prevent future sequelae, but these may lead to an inferior outcome, complications, and failure.1-4 This letter adds to the literature written on the duty of surgeons to fit intraoperative findings to the clinical syndromes and diagnoses and to follow the preoperative plans meticulously. Surgery is performed to solve clinical problems, not further them. David G. Mendes, MD Haifa, Israel