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-
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.
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-
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.
Acute infections of the hip joint could be treated by arthroscopic washout instead of a open procedure.
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.
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 .
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-
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-
- Snapping iliotibial band syndrome
- Snapping iliopsoas tendon syndrome
- 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-
(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-
With recent advances in hip arthroscopy, intra-
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 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.
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: