Hip Arthroscopy

History of Hip Arthroscopy

Arthroscopy of the hip joint was first described in the 1970’s and then further refined in the late 1980’s and early 1990’s. Recent advances in the development of surgical equipment have allowed orthopaedic surgeons to treat conditions that were traditionally either ignored or treated with an open procedure. The procedure has been popular in Europe for the past 15-20 years, but has only recently gained popularity in the United States over the past 5-10 years.

Because of its lack of popularity in the United States, few orthopaedic surgeons have advanced training in hip arthroscopy. However, as the procedure is becoming more accepted and more popular, more and more surgeons are becoming trained in this area of orthopaedic surgery.

Why has hip arthroscopy been slow to develop?

The hip arthroscopy procedure has been slower to evolve than arthroscopy of other joints (such as the knee and shoulder) because the hip is much deeper in the body and therefore less accessible. Furthermore, because the hip is a “ball and socket”-type joint, it is necessary to employ traction so as to expose the joint enough to fit the surgical instruments inside the joint without causing further damage to the cartilage and labrum.

What happens during a hip arthroscopy?

Hip arthroscopy, or a “hip scope,” is a minimally-invasive procedure. The use of an arthroscope means that the procedure is done using 2-3 small incisions (approximately 1/4-1/2 inch long) rather than a more invasive “open” surgery that would require a much larger incision. These small incisions, or “portals", are used to insert the surgical instruments into the joint.

Aiding other advances in arthroscope technology, the flow of saline through the joint during the procedure provides the surgeon with excellent visualization. The surgeon is also aided by fluoroscopy, a portable x-ray apparatus that is used during the surgery to ensure that the instruments and arthroscope are inserted properly.

A patient being set up for traction

The location of the incisions and instruments for the procedure

The instruments include an arthroscope, which is a long thin camera that allows the surgeon to view the inside of the joint, and a variety of “shavers” that allow the surgeon to cut away (debride) the frayed cartilage or labrum that is causing the pain. The shaver is also used to shave away the bump(s) of bone that are responsible for the cartilage or labral damage.

In addition to removing frayed tissue and loose bodies within the joint, occasionally holes may be drilled into patches of bare bone where the cartilage has been lost. This technique is called "microfracture" and promotes the formation of new cartilage where it has been lost.

The procedure is normally done as an “outpatient” surgery, which means the patient has the surgery in the morning and can go home that same day.

What is the recovery time associated with hip arthroscopy?

Following the procedure, patients are normally given crutches to use for the first 1-2 weeks to minimize weight-bearing. A post-operative appointment is normally held a week after the surgery to remove sutures. Following this appointment, the patient normally begins a physical therapy regimen that improves strength and flexibility in the hip.

After six weeks of physical therapy, many patients can resume normal activities, but it may take 3-6 months for one to experience no soreness or pain following physical activity. As no two patients are the same, regular post-operative appointments with one’s surgeon is necessary to formulate the best possible recovery plan.

Who will benefit from hip arthroscopy and what are the possible complications?

Following a combination of physical and diagnostic exams, patients are deemed suitable for hip arthroscopy on a case-by-case basis. Patients who respond best to hip arthroscopy are active individuals with hip pain, where there exists an opportunity to preserve the amount of cartilage they still have. Patients who have already suffered significant cartilage loss in the joint may be better suited to have a more extensive operation, which may include a hip replacement.

Studies have shown that 85-90% of hip arthroscopy patients return to sports and other physical activities at the level they were at before their onset of hip pain and impingement. The majority of patients clearly get better, but it is not yet clear to what extent the procedure stops the course of arthritis. Patients who have underlying skeletal deformities or degenerative conditions may not experience as much relief from the procedure as would a patient with simple impingement.

As with all surgical procedures, there remains a small likelihood of complications associated with hip arthroscopy. Some of the risks are related to the use of traction. Traction is required to distract and open up the hip joint to allow for the insertion of surgical instruments. This can lead to post-surgery muscle and soft tissue pain, particularly around the hip and thigh. Temporary numbness in the groin and/or thigh can also result from prolonged traction. Additionally, there are certain neurovascular structures around the hip joint that can be injured during surgery, as well as a chance of a poor reaction to the anesthesia.

Conclusion

Hip arthroscopy is indicated when conservative measures fail to relieve symptoms related to femoro-acetabular impingement, a condition that has been poorly understood and under-treated in the past. Advances have made hip arthroscopy a safe and effective alternative to open surgery of the hip, a tremendous advantage in treating early hip conditions that ultimately can advance to end-stage arthritis.