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HIP ARTHROSCOPY


Hip arthroscopy is a newly emerging technique for diagnosing and treating hip problems which were not diagnosed until few years ago. Most people would be familiar with knee arthroscopy (key hole surgery) and is quite a common procedure done for treating knee problems like cartilage tear, ligament injuries etc., Knee arthroscopy is also relatively straightforward.

However, hip arthroscopy is a more specialized procedure and is less commonly done than a knee arthroscopy. It is also more difficult procedure than a knee arthroscopy (as it is much deeper than the knee joint) and only very few orthopaedic surgeons are trained in performing hip arthroscopy. As it is a relatively new procedure, the use of hip arthroscopy in diagnosing and treating hip problems is still evolving.

The procedure is usually done under general anaesthetic and often combined with a mini-open procedure depending on the condition being treated. The hip joint is distracted by a special traction table to introduce the camera into the hip joint.

Hip arthroscopy is used to treat various conditions of the hip joint as follows:

Labral tear: It is being increasingly recognized that groin pain and mechanical symptoms of the hip like painful clicking could be due to labral tear. This could be either trimmed or repaired depending on the pathology.

Hip impingement:

Femoroacetabular impingement (FAI) is also a recently recognised condition producing hip symptoms in young adults. This is essentially due to clearance problem between the ball and the cup of the hip joint. This condition is also now considered to lead to hip arthritis in young adults. The abnormal bumps of the bone could be either treated by arthroscopy are with in combination with a mini-open procedure.  

Loose bodies:

Very rarely loose bodies in the hip joint can lead to mechanical symptoms like locking or giving away and could be removed using hip arthroscopy.

Infection:

Acute infections of the hip joint could be treated by arthroscopic washout instead of a open procedure.

Biopsy:

Occasionally a sample of tissue could be taken from the hip joint for analysis. There are other emerging pathologies like ligamentum teres injury etc., which may be amenable to arthroscopic treatment.

Peri-trochanteric probelms:

Trochanteric bursitis is a common condition which is usually treated with steroid injections. However, it is now being recognized that in some cases, there may be a tear of the abductor muscles (similar to the rotator cuff tear in the shoulders). Arthroscopy can be used to diagnose and repair the abductor tear although the success rate is not universal.

Iliotibial band snapping syndrome: 

In this condition, the iliotibial band becomes thick and taut. As the hip is flexed and extended, the iliotibial band flips to the front and back of the greater trochanter resulting in a visible snapping. Usually the condition is pain free and the main line of treatment is conservative including physiotherapy. Very rarely if the snapping is painful and does not improve with conservative treatment, surgical treatment could be contemplated. In the past, the surgery involved a relatively big incision to release the tight iliotibial band. However, recent advances allow the release of the iliotibial band to be done through key hole surgery .

Complications:

One of the common complications is some numbness in the thigh or perineal area due to the traction applied. Usually they recover with time but sometimes it may persist. Very rarely, a more serious damage to the nerves or blood vessels can occur. Bleeding, infections etc., are very rare. Other complications like new bone formation, stiffness, femoral neck fracture etc., may rarely occur depending on the type of the procedure done.

Advances in hip arthroscopy is now allowing the surgeons to examine the hip joint in a much more detailed way compared to the past although still the technique is still evolving. Technically it is still a difficult procedure compared to for example a knee arthroscopy.

Initially, the arthroscopy allowed the surgeons to examine the articular part of the hip joint (joint surface). With increasing knowledge and understanding of hip pathologies like labral tear, impingement syndrome of the hip etc., surgeons have started using the arthroscopic technique to treat those hip joint conditions in addition to diagnosing them.

In addition, techniques are also being developed to access the peripheral compartment of the hip joint and treat pathologies like CAM impingement etc., (although many surgeons utilise a combination of hip arthroscopy and mini-open procedure for managing those conditions).

The following is a video demonstration of arthroscopic management of CAM impingement which has been kindly provided by Dr Lavigne and Dr Vendittoli, Consultant Orthopaedic Surgeons at the Rosemont Maisonneuve Hospital, Montreal,Canada where Mr.Ganapathi did his advanced adult lower limb fellowship.

While mechanical symptoms of the hips are uncommon (unlike the knee joint), in some patients it can be one of the presenting symptoms. These include clicking sensation (which may be palpable or audible), a feeling of the hip coming out of the joint, locking or as a visible snapping (as in iliotibial band). As long as the mechanical symptoms are not painful, it is probably best to leave things alone.

There are a number of causes which can produce mechanical hip symptoms. They may be due to extra-articular causes (outside the hip joint) or intra-articular (inside the hip joint). With the advances in hip arthroscopy, a number of causes for mechanical symptoms are being recognised.

Extra-articular causes:

  • Snapping iliotibial band syndrome
  • Snapping iliopsoas tendon syndrome

Intra-articular causes:

  • Labral tears
  • Loose bodies
  • Synovial chondramatosis

Snapping iliotibial band syndrome:

In this condition, the iliotibial band (a thickened tissue over the outer aspect of the hip and thigh) becomes taut and produces an obvious (often visible) snapping as it slides over the greater trochanter (outer prominence of the hip) with flexion and extension of the hip. This is one of the commonest causes of snapping hip. Asymptomatic snapping hip should be considered benign and normal occurrence particularly in athletes. Even when the snapping becomes symptomatic and painful, the mainline of treatment is an extended period of non-operative treatment including stretching exercises, physiotherapy, activity modification and anti-inflammatories. In rare cases, where conservative treatment has not helped, surgical treatment could be considered. A number of surgical procedures have been described in the literature and majority involves a large scar including Z plasty of the iliotibial tendon.  With recent advances in hip arthroscopy, it is now possible to do the release of the taut iliotibial band through keyhole surgery thus minimising the scar over the outer aspect of the hip. However, it is important to understand that the results of the surgical procedures are variable and not always successful and hence the emphasis that non-operative treatment should be considered as the mainline of treatment.

(The following video shows Mr.Ganapathi performing an arthroscopic release of the snapping iliotibial band)


Snapping iliopsoas tendon syndrome:

In this condition, the  iliopsoas tendon (a muscle which originates in the spine and pelvis and attaches to the thigh bone) rubs over the iliopectineal eminence (a bony prominence on the front of the pelvis) or over the femoral head. This can produce a snapping sensation when the patient extends the hip from a flexed position. The snapping may be painful and may be related to sports or exercise activity. The treatment in majority of cases is non-operative with physiotherapy, activity modification, pain killers, anti-inflammatories etc.,  Further investigations include either a dynamic ultrasound or MRI scan. If there is clinical suspicion of psoas tendonitis, ultrasound guided steroid injection could be done which can improve the symptoms. If the symptoms do no improve with non-operative treatment, then surgical release could be considered but the results are not always successful.

Labral tears:

With recent advances in hip arthroscopy, intra-articular causes of painful snapping are being recognised including labral tears. The labral tears are in a way similar to the cartilage tears in the knee producing pain and mechanical symptoms but usually caused by repetitive injury (impingement syndrome) rather than due to an acute injury.

Pain over the lateral aspect of the hip (outer aspect) is quite a common clinical problem. It could be due to a number of reasons, including pain from the lower back as well as hip arthritis. One of the common causes is trochanteric bursitis and is usually treated by pain killers and local steroid injections.

It is now being recognised that in a small proportion of the cases, the pain may be due to tear in the abductor muscles of the hip (gluteus minimus/gluteus medius – the muscle which hold the pelvis level during single-leg stance) at their insertion into the greater trochanter. This is now considered to be similar to the “rotator cuff tear” of the shoulder and occurs due to chronic attrition. While the shoulder rotator cuff problems have been well recognised for a long time and the treatment is well evolved, the diagnosis and management of the “hip abductor problem” is still evolving.

The clinical diagnosis is based on the location of pain, temporary response to steroid injection, weakness of abductors, positive Trendelenberg test, pain during passive abduction etc., although not all signs may be present.

When a clinical diagnosis is suspected, further investigation is required to evaluate the problem. Either ultrasound or MRI scan can be done. MRI scan is probably better as the ultrasound interpretation is dependant on the person who does the ultrasound.

The management depends on the symptoms and the MRI findings. Although the long term results of repairing such an abductor tear is not known (as the condition is being recognised as a cause of hip pain only recently and the awareness about this condition among health professionals including orthopaedic surgeons is still scarce), recent studies have shown favourable short term results following surgical repair of the abductor tear. However, if there is significant fatty degenerative changes and wasting of the muscles, the results are likely to be less than optimal. Hence it is important to understand that the results may not be always successful.

The surgical treatment involves a open repair procedure although with advances in key hole surgery it is also possible to do the repair through key hole procedure. After the surgery, the repair should be protected with partial weight bearing with crutches for about 6 weeks.


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MRI scan showing trochanteric bursitis and partial tear of the abductors in left hip.

The following video shows Mr.Ganapathi performing an arthroscopic assessment of an abductor tear and mini-open repair of the abductor tear using suture anchors

 

The following are some relevant selected scientific references:

1. Surgical repair of chronic tears of the hip abductor mechanism.

Hip Int. 2009 Oct-Dec;19(4):372-6.
Davies H, Zhaeentan S, Tavakkolizadeh A, Janes G.
Avon Orthopaedic Centre, Bristol, UK.

Lateral sided hip pain frequently presents to the orthopaedic clinic. The most common cause of this pain is trochanteric bursitis. This usually improves with conservative treatment. In a few cases it doesn’t settle and warrants further investigation and treatment. We present a series of 28 patients who underwent MRI scanning for such pain, 16 were found to have a tear of their abductors. All 16 underwent surgical repair using multiple soft tissue anchors inserted into the greater trochanter of the hip to reattach the abductors. There were 15 females and 1 male. All patients completed a self-administered questionnaire pre-operatively and 1 year post-operatively. Data collected included: A visual analogue score for hip pain, Charnley modification of the Merle D’Aubigne and Postel hip score, Oxford hip score, Kuhfuss score of Trendelenburg and SF36 scores.Of the 16 patients who underwent surgery 5 had a failure of surgical treatment. There were 4 re ruptures, 3 of which were revised and 1 deep infection which required debridement. In the remaining 11 patients there were statistically significant improvements in hip symptoms. The mean change in visual analogue score was 5 out of 10 (p=0.0024) The mean change of Oxford hip score was 20.5 (p=0.00085). The mean improvement in SF-36 PCS was 8.5 (P=0.0020) and MCS 13.7 (P=0.134). 6 patients who had a Trendelenburg gait pre-surgery had normal gait 1 year following surgery.We conclude that hip abductor mechanism tear is a frequent cause of recalcitrant trochanteric pain that should be further investigated with MRI scanning. Surgical repair is a successful operation for reduction of pain and improvement of function. However there is a relatively high failure rate.

2. Advanced techniques in hip arthroscopy.

Instr Course Lect. 2009;58:423-36.
Larson CM, Guanche CA, Kelly BT, Clohisy JC, Ranawat AS.
Twin Cities Orthopaedics, Minneapolis, Minnesota, USA.

The indications for hip arthroscopy are expanding as the understanding of hip disease increases. Improved instrumentation and technical skills also have facilitated the ability to treat some hip disorders arthroscopically. Femoroacetabular impingement (FAI) is increasingly recognized as a disorder that can lead to progressive intra-articular chondral and labral injury. Although FAI is usually treated through an open approach, limited-open and all-arthroscopic approaches have been described. Various arthroscopic techniques allow treatment of labral and acetabular rim pathology as well as peripheral compartment femoral head-neck abnormalities. Early outcomes of limited-open and all-arthroscopic treatment of FAI are only beginning to be reported but appear to compare favorably with those of open dislocation procedures. Although labral tears traditionally have been treated with simple débridement, concerns have been raised about the consequences of removing the labrum. Modified portal placement and hip-specific suture anchors are now being used in an effort to repair some labral tears. Snapping hip disorders typically are treated nonsurgically. For persistent symptoms, arthroscopic release is successful, compared with open release, and allows additional evaluation of the hip joint during surgery. Diagnosis and management of traumatic and atraumatic hip instability continue to be challenging. Hip arthroscopy has been shown to be effective in the treatment of hip instability in some patients. The extra-articular peritrochanteric space is receiving increased attention. The arthroscopic anatomy has been well defined, but the treatment of greater trochanteric pain syndrome and arthroscopic repair of abductor tendon tears are only beginning to be reported. Improved techniques and longer-term outcomes studies will further define the optimal role of hip arthroscopy.

3. Endoscopic repair of gluteus medius tendon tears of the hip.

Am J Sports Med. 2009 Apr;37(4):743-7.
Voos JE, Shindle MK, Pruett A, Asnis PD, Kelly BT.
Hospital for Special Surgery, New York, NY 10021, USA.

BACKGROUND: Tears of the gluteus medius tendon at the greater trochanter have been termed “rotator cuff tears of the hip.” Previous reports have described the open repair of these lesions. HYPOTHESIS: Endoscopic repair of gluteus medius tears results in successful clinical outcomes in the short term. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: Of 482 consecutive hip arthroscopies performed by the senior author, 10 patients with gluteus medius tears repaired endoscopically were evaluated prospectively. Perioperative data were analyzed on this cohort of patients. There were 8 women and 2 men, with an average age of 50.4 years (range, 33-66 years). Patients had persistent lateral hip pain and abductor weakness despite extensive conservative measures. Diagnosis was made by physical examination and magnetic resonance imaging and was confirmed at the time of endoscopy in all cases. At the most recent follow-up, patients completed the Modified Harris Hip Score and Hip Outcomes Score surveys. RESULTS: At an average follow-up of 25 months (range, 19-38 months), all 10 patients had complete resolution of pain; 10 of 10 regained 5 of 5 motor strength in the hip abductors. Modified Harris Hip Scores at 1 year averaged 94 points (range, 84-100), and Hip Outcomes Scores averaged 93 points (range, 85-100). There were no adverse complications after abductor repairs. Seven of 10 patients said their hip was normal, and 3 said their hip was nearly normal. CONCLUSION: With short-term follow-up, endoscopic repair of gluteus medius tendon tears of the hip appears to provide pain relief and return of strength in select patients who have failed conservative measures. Further long-term follow-up is warranted to confirm the clinical effectiveness of this procedure.

4. Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip.

Arthroscopy. 2007 Nov;23(11):1246.e1-5.
Voos JE, Rudzki JR, Shindle MK, Martin H, Kelly BT.
Hospital for Special Surgery, New York, New York 10021, USA.

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

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