SPORTS HIP SURGERY
HIP ARTHROSCOPY INTRODUCTION
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.
What is it?
- Recent concept. Common cause of hip pain in young adults.
- Proposed to be one of the causes of arthritis of the hip at younger age.
What are the mechanisms?
- Cam impingement (bony bump at the head neck junction damages the labrum and cartilage with flexion)
- Pincer impingement (over-
coverage of the acetabular wall – the labrum gets pinched between the acetabulum and femoral neck and gets damaged)
What are the symptoms?
- FAI usually presents in active young adults with slow onset of deep groin pain that may start after a minor trauma. During the initial stages of the disease, the pain is intermittent and may be exacerbated by excessive demand on the hip, such as from athletic activities including deep flexion of the hip or prolonged walking. The pain also may present after sitting for a prolonged period.
- Mechanical symptoms from the hip such as painful locking or giving way are common presenting feature if labral tear is present.
Whom does it affect?
- Cam impingement – more common in young active males (M:F 14:1, age range 21-
51, mean 32)
- Pincer impingement – More common in middle-
aged active females (M:F 1:3, age range 40- 57, mean 40)
(Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular Impingement: Radiographic Diagnosis—What the Radiologist Should Know AJR 2007; 188:1540-
- Often many have mixed type of impingement
What are the clinical signs?
- Anterior Impingement test –
Hip is flexed to 90 degrees. Hip then passively flexed further, adducted and internal rotation – Positive if it reproduces the pain similar to that experienced by the patient.
- Posterior impingement (uncommon) – The hip is passively hyperextended by hanging the leg over the end of the couch while keeping the opposite limb in neutral position. Pain is reproduced if passive external rotation of the extended leg.
Differential diagnosis of hip pain in young adults
- Acetabular dysplasia
- Avascular necrosis
- Snapping iliopsoas tendon
- Non hip causes like inguinal hernia etc.,
How do we investigate?
- Plain radiographs
Cam impingement: Bump over the anterolateral aspect of the femoral neck. Often obvious only in the horizontal beam lateral – hence the need to do both AP pelvis Xray and horizontal beam lateral when impingement syndrome is suspected. Various measurements like alpha angle etc.,
Pincer impingement: Cross over sign in standardised AP pelvis Xray – due to overcoverage of the anterior acetabular wall.
- MRI arthrogram – evaluates cartilage damage and labral tear. Also may show pathology like avascular necrosis.
An initial trial of nonsurgical treatment, which may include activity modification including restriction of athletic activities, and nonsteroidal anti-
- Surgical treatment:
1. Through open dislocation of the hip
2. Combined arthroscopy and mini-
3. Arthroscopic treatment
- Encouraging early results for symptomatic improvement in recent literature.
- Less optimal result when there is large area of cartilage damage or presence of early arthritis
- Still an evolving concept
- No long term studies are available to show that surgical treatment can prevent the progression of arthritis
Hip impingement is a recently recognised condition which can cause hip pain in young adults. Essentially in this condition, the clearance between the ball (femoral head) and the cup (socket) of the hip joint is less than adequate. Often this is due to an abnormal shape of the ball of the hip joint (CAM impingement) or over coverage of the cup of the hip joint (Pincer impingement). Often it is due to a combination of both factors. Hip impingement can also occur if the socket is deeper than normal and also if there is joint laxity allowing abnormal movement. Hip impingement can lead to damage to labrum (could be considered like a soft tissue bumper for the hip joint) and subsequently the articular cartilage (surface lining of the hip joint) can get damaged leading to arthritis in young adults.
In a normal hip, the “ball” moves inside the cup without any restriction (impingement).
CAM impingement can occur when the shape of ball of the hip joint is not a sphere and more like a rugby ball on one side or with a “impingement bump” on one side. This leads to less clearance and with repetitive bending movements of the hip the labrum (a special cartilage at the rim of the cup of the hip joint) and the articular cartilage (surface lining of the hip joint) gradually get damaged.
Pincer impingement occurs when there is over coverage of the cup of the hip joint and this leads to impingement. With repetitive bending movements of the hip, the labrum gets damaged initially followed by the articular cartilage.
Progressive damage to the cartilage can gradually lead to arthritis of the hip in young adults.
The most common symptom in hip impingement is pain in the region of the groin (front of the hip joint). It may start following a minor injury or often without any injury. The pain increases with activities which involve bending of the hip joint. Activities which increase the pain include sitting for a prolonged period, getting up from a seated position, getting in and out of the car, walking up and down slopes, climbing stairs, getting in and out of the bath tub, squatting, heavy work including push/pull, carrying heavy objects, putting on shoes and socks, twisting etc., Sporting activities may also be affected. While many of the above symptoms can also be present in patients with hip arthritis, the arthritic pain also increases with activities like walking and sometimes there may be pain even at rest. The patients with impingement can also have a sensation of the hip coming out of the hip joint and also a feeling of clicking sensation. This can be due to a labral tear although in some patients this could be due to dysplasia (shallow cup).
While the preliminary diagnosis of hip impingement is based on the symptoms and the clinical finding on examination, further radiological investigation including plain x-
rays showing CAM type impingement
rays showing the removal of the CAM (bump) from the femoral head
ray showing relatively normal looking hip but closer inspection
reveal calcification in the labral area and impingement cyst
suggesting possible impingement.
ray showing cross- over sign suggesting pincer impingement
(“figure of 8” sign, shaded area representing the overcoverage
of the acetabulum)
CT scan with 3 D reconstruction showing
CAM type impingement (shaded in green for
MR arthrogram showing labral tear
and impingement cyst
As the condition (hip impingement) is only being recently recognized as a cause of hip pain which can progress to hip arthritis in young adults, the treatment strategies are still evolving. In the initial stages, it would be appropriate to consider conservative treatment including physiotherapy, painkillers and activity modification.
If the symptoms persist, it would be appropriate to consider surgical option. When Ganz initially suggested this condition as a cause of hip pain, he advised surgery using a technique known as “surgical dislocation” of the hip. In this exposure, the hip joint is completely exposed (see picture below). While this still may be needed in some cases, the surgical exposure is extensive and carries certain morbidities including non-
Exposure of the femoral head with Ganz “surgical dislocation” of the hip
(the picture also shows the bony bump the so called “CAM lesion” to be excised)
Hip arthroscopy is a technically more challenging procedure when compared with a knee arthroscopy. However, with the advances in the technique of hip arthroscopy and instrumentation, treatment strategies are also evolving which makes it possible for at least some impingement pathologies to be treated entirely through hip arthroscopy.
CAM impingement resection through hip arthroscopy
Whatever the surgical technique may be, the treatment essentially entails creating better clearance for the ball of the hip joint. The bump in the anterolateral aspect of the ball is removed and/or the over covered part of the acetabulum is excised. The labral tear is often debrided but in some cases, the labrum could be repaired.
While studies have shown that many patients gain short term improvement in their symptoms, the symptom relief is not universal. One of the main negative predictors of symptoms relief is presence of arthritic changes or damage to the surface lining of the hip joint.
At this stage, there is lack of data to say whether surgical treatment of hip impingement can delay or prevent the progression to hip arthritis.
The following are some relevant selected scientific references:
1.Femoroacetabular impingement syndrome: an under recognized cause of hip pain and premature osteoarthritis?
2. Efficacy of Surgery for Femoroacetabular Impingement: A Systematic Review.
3. Combined hip arthroscopy and limited open osteochondroplasty for anterior femoroacetabular impingement.
4. Open treatment of femoroacetabular impingement is associated with clinical improvement and low complication rate at short-
5. Combined arthroscopic and modified open approach for cam femoroacetabular impingement: a preliminary experience.
6. Arthroscopic femoroplasty in the management of cam-
7. Femoroacetabular impingement treatment using arthroscopy and anterior approach.
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: