Hip arthroscopy

Introduction

Arthroscopies of the hip are a generally undeveloped field of orthopaedics. There are a number of very good reasons for this. It is a deep seated joint and therefore the ability to manoeuvre in such a joint is very limited. It requires the use of a traction table to put the hip open and therefore the entire set-up is cumbersome. It takes a lot longer to do than any of the other orthopaedic procedures. The pathologies that need to be addressed used to be felt to be “minor incumberences” rather than actual disorders. Nevertheless, there are very real issues that are faced with patients who have these relevant conditions. In the case below (Figure 1), this young athletic male was forced over 5 years to give up sport because he was told his hip was normal. He was given a cortisone injection to no avail. When he saw me for a second opinion it was clear however that he had a labral tear and cam-type femoroacetabular impingement and I felt that he would benefit from a hip arthroscopy procedure. These sorts of presentations are actually very common.


Figure 1. Up until a few years ago, patients with labral tears were forced to bear the pain. This patient was told he had a normal Xray and MRI. Closer inspection (a) shows sclerosis (whitening) of the acetabular(socket) rim (yellow arrow), a femoral neck bump or cam causing femoroacetabular impingement (green arrow) and even a cyst in the neck (red arrow). The MRI (b) showed mucoid degeneration on the anterior part of the labrum.

The procedure

In the past, one would have to open the hip through a 4 centimetre incision to take a look at what was happening. This would generally not be done as the surgery would be more damaging than the condition itself. With the advent of MRI, we were able to diagnose the lesions but still not offer surgery due to similar issues. Hence, there was a heavy dependence on anesthetic and anti-inflammatory injection. We began to perform arthroscopies for these conditions and this matched the indication well (Figure 2). The indication of hip arthroscopy is usually very specific. We look for a tear in the rim (labrum) and repair it and then we look for the cause of the tear which is usually a bump or cam on the neck. The procedure can take about 2 to 3 hours for a relatively small procedure (Figure 3).


Figure 2. Endoscopy of the patient in Figure 1 showed that the head or ball had already undergone wear (a) and there was an apparent labral tear (b). This had to be cleaned (c) and repaired after which the cam (bump) was trimmed- all done through two incisions less than a centimeter each.

Results

Results of hip arthroscopy have been good to excellent. There are occasional failures but the patient is not worse off than when he started. Overall it is comething to consider in a young patient with a normal xray and minimal MRI changes. Often labral tears are missed even on MRI evaluation and requires a specific ability and interest to evaluate these and determine if labral reapir or hip replacement surgery is more relevant.


Figure 3 (video). This edited video highlights the salient points of  a hip scope identification to repair. Bear in mind the entire reconstruction is focused to an area about 2 cm across(!) and it usually takes about 2 hours to do.