HIP ARTHROSCOPY

Hip arthroscopy (also known as keyhole surgery) is a surgical procedure that allows a view of the hip joint without making a large incision (cut) through the skin and other soft tissues. 

An arthroscope is a small, fibre-optic instrument that consists of a lens, light source and video camera. During hip arthroscopy, an arthroscope is inserted into your hip joint. The camera displays images on a large screen monitor, and this allows an assessment of any damage, the type of injury, and the ability to repair the problem using miniature surgical instruments. Because the arthroscope and surgical instruments are thin, only very small incisions are required, rather than the larger incision needed for open surgery. This results in less pain for patients, less joint stiffness, and often shortens the time it takes to recover and return to favourite activities.

A/Prof Woodgate may recommend hip arthroscopy if you have a painful condition that does not respond to nonsurgical treatment. Nonsurgical treatment includes rest, physical therapy, and medications or injections that can reduce inflammation.

Hip arthroscopy is used to diagnose and treat a wide range of hip conditions that damage the labrum, articular cartilage, or other soft tissues surrounding the hip joint, including:

• Removal of torn cartilage or bone chips that cause hip pain and immobility.
• Repair a torn labrum: The labrum is a fibrocartilage ring that attaches to the rim of the acetabular socket, sealing and stabilizing the joint. Removal of bone spurs or extra bone growths caused by arthritis or an injury. Femoroacetabular impingement (FAI) is a disorder in which extra bone develops along the acetabulum (pincer impingement) or on the femoral head (cam impingement). This bone overgrowth—called spurs—damages the soft tissues of the hip during movement. Sometimes bone spurs develop in both the acetabulum and femoral head.
• Removal of part of the inflamed synovium (lining of the joint) in patients with inflammatory arthritis. This procedure is called a partial synovectomy.
• Repair of fractures or torn ligaments caused by trauma.
• Dysplasia is a condition in which the hip socket is abnormally shallow. This puts more stress on the labrum to keep the femoral head within the socket, and makes the labrum more susceptible to tearing.
• Snapping hip syndromes cause a tendon to rub across the outside of the joint. This type of snapping or popping is often harmless and does not need treatment. In some cases, however, the tendon is damaged from the repeated rubbing.
• Loose bodies are fragments of bone or cartilage that become loose and move around within the joint.
• Hip joint infection. 
• Evaluation and diagnosis of conditions with unexplained pain, swelling, or stiffness in the hip that does not respond to conservative treatment.

Surgical Procedure

Hip arthroscopy is most commonly performed under general anaesthesia, where you go to sleep for the operation. 

Positioning

At the start of the procedure, your leg will be put in traction. This means that your hip will be pulled away from the socket enough to insert instruments, see the entire joint, and perform the treatments needed. Typically lines are drawn on the hip to indicate specific anatomy structures (such as bone, nerves, and blood vessels), as well as incision placements and portals for the arthroscope.

orthoinfo.aaos.org

Procedure

After light distraction is applied, a small puncture incision is made in your hip (about the size of a buttonhole) for the arthroscope. Through the arthroscope, the inside of your hip can be viewed and damage identified. Fluid flows through the arthroscope to keep the view clear and control any bleeding. Images from the arthroscope are projected on the video monitor. 

orthoinfo.aaos.org

Once the problem is clearly identified, other small instruments are inserted through separate incisions to perform the necessary procedures. Specialized instruments are used for tasks like shaving, cutting, grasping, suture passing, and knot tying. In many cases, special devices are used to anchor stitches into bone.

The length of the procedure will depend on what is identified and the amount of work to be done. At the end of surgery, the arthroscopy incisions are usually stitched, and an absorbent dressing is applied to the hip.

Advantages of Hip Arthroscopy

The advantages of hip arthroscopy over the traditional open hip surgery includes:

• Smaller incisions
• Minimal trauma to surrounding ligaments, muscles, and tissues
• Less pain
• Faster recovery
• Lower infection rate
• Less scarring
• Earlier mobilization
• Shorter hospital stay, usually only overnight.

Complications and Risks

Complications from hip arthroscopy are uncommon. Any surgery in the hip joint carries a small risk, and this may include:

• Infection at the surgical incision site or in the joint space.
• Nerve damage, which may cause numbness, tingling, or pain, and most commonly noted in the medial groin or perineal region (majority of these resolve by 6 weeks).
• Excess bleeding into the joint, a condition called haemarthrosis.
• Synovitis (inflammation of the lining of the joint from the surgical procedure)
• Failure of the repair of the labrum.
• Iatrogenic femoral neck fracture, particularly when there has been a “bumpectomy” for removal of the bony prominence on the femoral head/neck junction.
• Avascular necrosis of the femoral head.
• Hip instability.
• Blood clots may form inside the deep veins of the legs, which can travel to the lungs (pulmonary embolism).

Recovery

After surgery, you will stay in the recovery room for 1 to 2 hours before being transferred to the ward for an overnight stay. You can also expect to be on crutches, or a walker, for a short period of time.

Pain Management

After surgery, you will feel some pain. This is a natural part of the healing process. A/Prof Woodgate will instil an injection of local anaesthetic into the hip and the surgical wounds at the end of the procedure, which will help with pain management.

Medications

Medications are often prescribed for short-term pain relief after surgery. Many types of medicines are available to help manage pain, including Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs, and local anaesthetics. A combination of these medications is usually utilised to improve pain relief, as well as minimize the need for opioids.  Medication such as Aspirin or Clexane may also be used to lessen the risk of blood clots.

Bearing Weight

Crutches may be necessary after your procedure. In some cases, they are needed only until any limping has stopped (typically less than 48 hours), or longer if advised by A/Prof Woodgate.

Wound Care

The bulky, absorbent surgical dressing is lightened after 48 hours.  Clean waterproof dressings are applied to the surgical incision sites. There may be some bruising around the surgical wounds and upper thigh, which usually resolves over 3-4 weeks.

Physical Therapy 

In most cases, physical therapy is necessary to achieve the best recovery. Specific exercises to restore your strength and mobility are important. A/Prof Woodgate will also advise you with any additional restrictions during your rehabilitation.   This will include avoiding deep squatting and vigorous activities/sports. Everyday activities of daily living can be carried out as comfort allows.

Post-Operative Review

A/Prof Woodgate will normally advise review at 10-12 days, and this allows for review of the operative findings, removal of the surgical wound sutures, and advice for ongoing pain management and physical therapy.  A second review is normally scheduled for 6 weeks post surgery.

If at any stage there are concerns regarding your wound, or increasing pain (either at the surgical sit or elsewhere in the lower leg), it is important that you contact A/Prof Woodgate as soon as possible.