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Hip arthroscopy is a widely available and important treatment option for those patients experiencing hip pain and/or discomfort (or related groin pain which can often be a sign of problems with the hip joint), as well as being an invaluable tool in defining intra-articular injuries.
Arthroscopic procedures may be used for a variety of hip conditions, primarily the treatment of hip impingement, labral tears, articular cartilage injuries, the removal of loose bodies in the joint and snapping hip syndrome. Other less frequent conditions treated through hip arthroscopy include tendon or ligament injuries, hip instability, and an inflamed or damaged synovium.
Through an incision the width of a straw tip, a surgeon is able to insert a scope, which allows him or her to inspect the joint and locate the source of pain. The surgeon will then make one or more small incisions to accommodate the instruments used to treat the hip. These instruments can shave, trim, cut, stitch, or smooth the damaged areas.
Hip arthroscopy is less invasive than traditional open hip surgery, is often performed as a day-case and may require a shorter stay in hospital compared to traditional open hip surgery.
major indications for hip arthroscopy
|arthroscopic procedure required
|hip impingement (femoroacetabular impingement syndrome or FAI)
While the cause of hip impingement remains unknown, FAI is recognised as a cause of osteoarthritis.
Hip impingement is defined as abnormal bony contact during flexion and extension of the hip joint resulting in soft tissue failure.
Symptoms include sharp pain during deep hip flexion, internal rotation or abduction, and difficulty in squatting, stopping/starting quickly and moving laterally.
The surgeon will reshape the junction between the head and neck of the femur using small mechanical resection devices called burrs. Performing this step as well as trimming any excessive portion of the acetabulum will give the joint more clearance, thus relieving the impingement.
At various times during the surgery and immediately following it, the surgeon will test and monitor the range of motion of the hip.
A labral tear is an abnormal separation of the labrum or separation of the labrum from the acetabular rim.
Labral tears can be caused by trauma or degeneration. The most common cause of hip labral tears is the application of external force on the hyperextended, externally rotating hip.
Symptoms include painful hip flexion, adduction and internal rotation.
The surgeon will smooth the edges of the torn or frayed labrum using arthroscopic shaver blades or radiofrequency (RF) energy. Specially designed RF probes include flexible heads that allow the surgeon to manoeuvre through difficult curves in the hip joint, remove torn tissue and smooth the damaged areas. In some cases, the labrum may be repaired. For this procedure, anchors will be attached to the bone and sutures will be passed through the tissue. The anchors are used to hold the suture in place.
|articular cartilage injuries
When articular cartilage is damaged, the torn fragment often protrudes into the joint, causing pain when the hip is flexed.
In addition, the bone material beneath the surface no longer has protection from joint friction, which may eventually result in arthritis if left untreated.
Articular cartilage injuries often occur in conjunction with other hip injuries, and like labral tears, may require an MRI with a dye injection to confirm the diagnosis.
The surgeon will use an arthroscopic shaver blade to remove the damaged tissue, leaving a smooth stable surface.
Certain types of injuries may require treatment with microfracture. In this procedure, the surgeon will create a number of small holes in the exposed bone of the joint to induce bleeding and clotting, which also leads to new tissue growth. Studies indicate that in time, this new growth becomes firm tissue that is smooth and durable.
Diagnosis is usually evident on images or scans. Non-ossified loose bodies are extremely difficult to visualize.
When removing loose bodies, the surgeon will use an arthroscope to inspect the joint to confirm the number of loose bodies and their location. The surgeon will then remove the loose bodies using specially designed hand instruments called graspers.
|snapping hip syndrome
Snapping hip syndrome is a medical condition characterised by a snapping sensation and an audible click upon flexion and extension of the hip joint. It may be painful in the lateral (outside) part of the hip, or pain may be experienced in the groin area. Snapping hip syndrome can be either internal or external, and usually develops as the result of an acute injury or overuse of the joint. Athletes are particularly at risk due to the repetitive hip flexion involved in sports such as ballet, football, resistance training, rowing, running and gymnastics2.
External snapping hip syndrome is associated with leg length differences.
The surgeon must release the snapping iliopsoas tendon, or less commonly, the tensor fascia lata. During the procedure, the surgeon will rotate the hip and make two portals; one for the arthroscope and one for a specially designed radiofrequency (RF) probe. The RF probe has a flexible head, allowing the surgeon to release the tendon. This method is safer than open hip surgery, and studies have shown that there are minimal complications following the procedure.
Hip arthroscopy is performed as an outpatient procedure, and usually under general anaesthesia. Epidural anaesthesia is an appropriate alternative but requires an adequate motor block to ensure muscle relaxation.
Both 30° and 70° video arthroscopes can be used during hip arthroscopy although a 70° scope is used more frequently as it will often enhance visualisation, and will occasionally allow the surgeon to identify lesions that might be missed with the 30° scope.
A fluid management system is essential for optimising visualisation during arthroscopy. Use of a high flow system allows adequate flow without excessive pressure thereby reducing extravasation of fluid from the joint. Hip arthroscopy also requires arthroscopic hand instruments specifically designed for use in the hip joint.
Importantly, instruments commonly used in laparoscopic procedures may have the required extra length, but are fragile and may easily break if used in the hip. Consequently, endoscopic hand instruments are contraindicated for use during hip arthroscopy.
Three standard portals are used for hip arthroscopy:
Systematic examination and operative arthroscopy of the hip are facilitated by interchanging the instruments and arthroscope between the three established portals. The structures that can dependably be visualised include: the superior weight bearing portion of the acetabulum; the fossa; the ligamentum teres; and the anterior, posterior and lateral aspects of the acetabular labrum. Most of the weight bearing articular portion of the femoral head can be visualised intra-operatively by internally and externally rotating the hip.
Hip arthroscopy is contraindicated in the presence of ankylosis or advanced arthrofibrosis. Soft tissue compromise, whether from disease, trauma or previous surgery, may contraindicate the passage of instruments into the hip joint. Similarly, bony compromise, either of the joint architecture or potential stress risers, regardless of the cause, may contraindicate application of the distraction forces necessary for hip arthroscopy.
For hip arthroscopy, extra length instruments are usually necessary, even for moderate sized patients. Consequently, severe obesity may be a relative contraindication to arthroscopic intervention.
Advanced disease states with destruction of the hip joint also contraindicate arthroscopy as there can be no reasonable expectation of symptomatic improvement.
Nerve injury is uncommon, but can be an issue with any form of hip surgery. Injury to any of the nerves can cause pain and other problems. Other possible complications associated with hip arthroscopy include additional injury to the hip joint, infection, and continued pain after the surgery3.professional education