Arthroscopic surgery is a minimally invasive surgical technique for management of injuries to various joints of the body. Small incisions are made in the skin for placement of an arthroscope and specialized instruments. The shoulder and knee are the most common joints treated arthroscopically. These joints are superficial and therefore easily accessed with arthroscopic instrumentation. In contrast, arthroscopic surgery of the hip is significantly more challenging. The hip joint is composed of a spherical femoral head, and deeply recessed acetabulum that is convex in shape, making access to the joint more difficult (figure 1). In addition, a thick capsule and muscular envelope surround the hip joint, and several important neurovascular structures including the sciatic and femoral nerves and the femoral artery and vein lie in close proximity to the joint.
Arthroscopic surgery of the hip was first introduced in 1931, but remained extremely rare throughout the remainder of the century. In the late 1990s, as instrumentation improved, and a better understanding of the arthroscopic anatomy of the hip developed, arthroscopic surgery of the hip became more common. Several specialized Sports Medicine Fellowship training programs, performed after completion of 5 years of general training in Orthopaedic Surgery, now include arthroscopic management of injuries to the hip.
Patients with hip pathology are often misdiagnosed for significant periods of time. Lumbar spine, genitourinary, intra-abdominal and abdominal wall pathology may be erroneously considered sources of pain emanating from the hip joint. Improved understanding of hip pathology has led to identification of many conditions not recognized in years past, and therefore not considered in patients with hip pain.
Patients with hip pathology may suffer from pain in the groin, thigh, buttock, outer hip or inner knee. Symptoms may include poor range of motion, clicking, locking or catching. Symptoms may develop insidiously over years, or more commonly following an acute traumatic event. Pain and catching may be aggravated by athletic activities such as running, jumping and twisting. Symptoms typically abate with rest. Persistent symptoms beyond 4 weeks require specialty evaluation to assess for significant pathology.
Advances in imaging studies have also improved our understating of the hip joint. Radiographs (x-rays) remain important in the assessment of bony abnormalities of the hip, and play an important role in confirming the absence of advanced arthritis of the hip, a condition not amenable to arthroscopic surgery. MRI with dye injected into the joint (MR arthrogram) has become the imaging modality of choice in assessing the hip joint. Injection of dye into the joint significantly improves our ability to visualize damage to the labrum and articular cartilage. These structures are not visualized on radiographs and are poorly visualized on regular MRI.
Most hip pain is effectively managed without surgery. Appropriate rest, activity modification and anti-inflammatory medications are the initial treatment options for common conditions. Physical therapy may be an effective modality to prevent recurrence of pain. In patients with persistent pain that is reproducible with physical exam, and in whom there is radiographic or MRI evidence of pathology, hip arthroscopy may be of significant benefit. Arthroscopic surgery of the hip may also be useful as a diagnostic tool in patients whose imaging studies are inconclusive but have persistent pain attributable to the hip joint.
Common hip joint conditions amenable to arthroscopic treatment include removal of loose or foreign bodies, removal or smoothing of cartilage damage (chondral injuries), debridement or repair of the acetabular labrum (figure 2), management of femoroacetabular impingement (FAI), management of joint infections as well as synovitis (inflammation of the lining of the joint), and investigation of painful joint replacements. In addition, several conditions outside the hip joint are amenable to arthroscopic treatment including management of internal and external snapping hips, debridement of trochanteric bursitis and repair of tears of the abductor muscles (similar to rotator cuff repair in the shoulder). Rarely, hip arthroscopy may be used to manage mild-to-moderate arthritis.
Hip arthroscopy is performed as an outpatient procedure, with patients returning home the same day as surgery. Most procedures are performed with 2 small incisions, each measuring approximately 1 cm. Based on the procedure performed patients may be weight-bearing as tolerated immediately following the surgery, or require crutches for several weeks. Physical therapy is initiated and sutures are removed within 2 weeks. Many patients are instructed to begin riding a stationary bicycle as early as the first post-operative day. Significant discomfort requiring prescription pain medication usually lasts less than 1 week. Final recovery from surgery is typically achieved within 6-12 weeks.
Dr. Gabriel D. Brown is an Orthopaedic Surgeon with specialty training in Sports Medicine. He completed a Sports Medicine Fellowship at Kerlan Jobe Orthopaedic Clinic in Los Angeles, CA, where he assisted in the care of professional athletes including the LA Lakers and LA Dodgers. He specializes in the surgical and non-surgical management of sports medicine injuries and arthroscopic surgery of the shoulder, elbow, hip and knee.