Minimally Invasive Surgery (Arthroscopy)

Hip Arthroscopy

Anatomy

The hip is a ball-and-socket joint. The socket is formed by the acetabulum, which is part of the large pelvis bone. The acetabulum is ringed by strong fibrocartilage (the labrum) that forms a gasket around the socket. The ball is formed by the femoral head, which is the upper end of the thighbone (femur). The surfaces of both the ball and socket are covered with a smooth tissue (articular cartilage) that cushions the ends of the bones and enables them to glide across each other with ease. The hip joint is surrounded with synovial membrane, a thin tissue that produces a small amount of fluid to lubricate the cartilage and eliminate nearly all friction during hip movement. The ball and socket are connected by bands of tissue (ligaments) that form the hip capsule and provide stability to the joint.

Description

Arthroscopy is a minimally invasive surgical procedure used by orthopedic surgeons to visualize, diagnose and treat a wide range of problems inside the joint. During hip arthroscopy, a small camera (arthroscope) is inserted into the hip joint and images from inside the hip are displayed on a video monitor. Referring to these images during the procedure enables the orthopaedic surgeon to guide the miniature surgical instruments more precisely.

Because the arthroscope and surgical instruments are thin, very small incisions (cuts) can be used to perform arthroscopic surgery, instead of the larger incisions required for open surgery. This minimally invasive approach results in less pain and joint stiffness, and it often shortens recovery time so patients can return to favorite activities more quickly. Hip arthroscopy has been performed successfully for many years, however, it is not as common as knee or shoulder arthroscopy.

Hip Arthroscopy Recommendation

Your orthopaedic surgeon may recommend hip arthroscopy if you have a painful condition that does not respond to nonsurgical treatments such as rest, physical therapy, and medications or injections to reduce inflammation. This procedure may relieve painful symptoms associated with injuries or other problems that damage the labrum, articular cartilage or other soft tissues surrounding the joint. Orthopaedic conditions that frequently can be treated with hip arthroscopy include:

• Femoroacetabular impingement (FAI)—FAI (which is frequently associated with a labral tear) is a disorder in which extra bone (bone overgrowth or spurs) develops along the acetabulum (pincer impingement) or femoral head (cam impingement), or both areas. This bone overgrowth damages the soft tissues (labrum) of the hip during movement.
• Snapping hip syndromes—Although this type of snapping or popping is often harmless and requires no treatment, in some cases, the tendon is damaged by the repeated rubbing across the outside of the joint.
• Synovitis—A condition characterized by inflammation of the tissues that surround the joint (synovial lining).
• Loose bodies—Small fragments of bone or cartilage that have become loose or broken off inside the joint can cause pain or may even get caught in the moving parts of the joint.
• Hip joint infection
• Not all hip problems can be treated arthroscopically—People with hip arthritis or with hip dysplasia (abnormally shallow hip socket puts excess stress on the labrum to keep the femoral head within the socket; this makes the labrum more susceptible to tearing) generally are not good candidates for hip arthroscopy.

Preparation for Surgery

Once the decision to have surgery is made, your orthopaedic surgeon will require some preparations, such as having an evaluation by your primary care physician, or specialists for any chronic medical conditions, to assess your general health before surgery and determine if any problems exist that may interfere with the procedure. If certain health risks are identified, a more extensive evaluation may be required before surgery.

• Current medications or supplements—Be sure to inform your orthopaedic surgeon of any and all medications or supplements that you are taking. You may have to stop taking some of these before your surgery.
• Important instructions—Prior to your procedure, the hospital or surgical center will contact you with specific details, such as what time you should arrive, and when you must stop eating and drinking before surgery. Be sure you understand these instructions completely and follow them exactly as directed.

Surgical Treatment

If it is determined that your health is generally good, your hip arthroscopy is likely to be performed on an outpatient basis, which means you will not have to remain in the hospital overnight.

• Anesthesia—Before surgery you will be evaluated by a member of the anesthesia team. General anesthesia (you are asleep for the entire operation) is most commonly used for hip arthroscopy. However, regional anesthesia, such as spinal or epidural (you are awake but numb from the waist down), can also be used. Your orthopaedic surgeon and anesthesiologist will talk to you about these methods and with your input, determine the best option for you.
• Positioning—At the start of the procedure, your leg will be put in traction so that the hip is pulled away from the socket far enough to allow your orthopaedic surgeon to insert instruments, view the entire joint and perform the necessary treatments. Surgeons typically draw lines on the hip to clearly indicate specific anatomy structures such as bone, nerves and blood vessels, as well as incision placements and portals for the arthroscope.
• Surgical procedure—A small incision about the size of a buttonhole will be made in the hip to allow insertion of the arthroscope. Fluid flows through the arthroscope to keep the view clear and control any bleeding as images from inside the hip joint are projected onto a video screen. Once the problem is identified, your orthopaedic surgeon will insert small instruments through separate small incisions to make the repair. Specialized instruments will be used to perform tasks such as shaving, cutting, grasping, suture passing, knot tying or anchoring stitches into bone.
• Timing and completion—The length of time required for your surgery will depend upon what problems the arthroscopy reveals and the amount of work required to repair your hip joint. Once the surgery has been completed, the arthroscopy incisions are typically stitched or covered with skin tapes, followed by application of an absorbent dressing.

Recovery

Following surgery, you will remain in the recovery room for 1 to 2 hours before being discharged. You will need someone to drive you home and stay with you, at least the first night.

• Bearing weight and using crutches—After your procedure, you may need to use crutches or a walker for a period of time. In some cases, they are needed only until any limping has stopped, however, if your procedure was more extensive you may need crutches for 1 to 2 months. Call your orthopaedic surgeon if you have any questions about bearing weight.
• Rehabilitation exercise—Your surgeon will develop a rehabilitation plan based on the surgical procedures you required. In most cases, physical therapy is necessary to achieve the best recovery and specific exercises to restore strength and mobility are important. Your therapist can also provide guidance regarding what you should and should not do during your rehabilitation.

Pain Management and Medication

Pain is a natural part of the healing process but reducing it can help you recover from surgery more quickly. Many types of medicines are available for short-term pain relief after surgery. These include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs) and local anesthetics. Your physician may use a combination of these medications to improve pain relief and minimize the need for opioids.

Whether you are taking pain medications in over-the-counter or prescription strengths, they must be used carefully. If you are taking them for more than one month, or if you develop reflux or stomach pains while taking an anti-inflammatory, be sure to talk with your physician immediately.

• Opioids—Although opioids can provide relief from pain after surgery, they are a narcotic and can be addictive—it is important to only use them as directed by your physician. In fact, opioid dependency and overdose has become a critical public health issue in the United States. Stop taking opioids as soon as pain begins to improve and if this doesn't occur within a week of surgery, talk to your doctor.
• Other medications—Your physician may also recommend aspirin or other drugs to lessen the risk of developing blood clots after surgery.

Complications

Complications from hip arthroscopy are uncommon. However, with any surgery there are some risks and these vary from person to person. Any surgery in the hip joint carries a small risk of injury to surrounding nerves, blood vessels or the joint itself. Although the traction necessary for the procedure can stretch the nerves and cause numbness, this is usually temporary. Other small risks include infection or blood clots in the legs (deep vein thrombosis). Prior to surgery, your orthopaedic surgeon will explain any potential risks and complications that may be associated with your procedure.

Long-Term Outcomes

Many people return to full, unrestricted activities after arthroscopy. Your individual recovery will depend on the type of damage that was present in your hip. Lifestyle changes are sometimes necessary to protect the joint, such as switching from a high impact exercise like running, to swimming, cycling or another lower impact activity. These are decisions you will make with the guidance of your surgeon. In cases of severe damage that cannot be completely reversed, the procedure may not be successful.

Future Developments

Arthroscopy has allowed physicians and researchers to gain a better understanding of many hip joint problems. As surgical techniques continue to evolve, hip arthroscopy is expected to play an increasingly important role in the diagnosis and treatment of hip disease.