What is hip arthroscopy?
Recent advances in the development of surgical equipment have allowed orthopedic surgeons to treat conditions that were traditionally either ignored or treated with an open procedure. Now, with just a small incision, a surgeon can insert a pencil-sized optical device into the hip joint, which relays an image to a large video monitor in the operating room, allowing a surgeon to see into the joint and correct problems.
Step-by-step of a hip arthroscopy
Hip arthroscopy, or a “hip scope,” is a minimally-invasive procedure. The use of an arthroscope means that the procedure is done using 2-3 small incisions rather than a more invasive “open” surgery that would require a much larger incision. These small incisions, or “portals,” are used to insert the surgical instruments into the joint. Occasionally, a third or fourth incision may be required depending upon the procedure.
The patients are placed supine (on the back) and traction is applied under the guidance of fluoroscopy to allow for the placement of instruments. The amount of force needed to distract the hip varies from patient to patient, with every effort made to minimize the amount of traction. This practice decreases the amount of neurapraxia that develops post-operatively.
Through the second opening, surgical instruments are inserted to shave tissue, cauterize structures or remove pieces. On occasion, holes may be drilled into patches of bare bone where the cartilage has been lost. This technique, called “microfracture” or “picking,” provokes localized bleeding and encourages the formation of fibrocartilage (repair cartilage). Saline is pumped through the joint during the procedure to improve visualization and flush out debrided tissue.
Hip Arthroscopy Procedures
When the inflamed synovial lining of the hip joint causes disabling pain, it may have to be removed via synovectomy. By inserting heat-generating radio frequency probes inside the joint capsule, the inflamed tissue is then removed.
The location, chronicity and vascularity of the injured fibrocartilage determine the way that labral tears are treated, with the goal of preserving as much healthy labral tissue as possible.
If the quality of the labral tissue is poor, a debridement of the labrum is performed. This is done with the use of a rotating shaver in the joint that “trims” away involved tissue.
If the quality of the labral tissue is adequate, an anchor is placed into the bone (acetabular rim). The suture attached to the anchor is then fed around the labral tissue and tied down to the acetabulum. This refixation procedure should make it possible for scar tissue to grow down the acetabulum and remain there once the suture dissolves.
Partial Psoas Release
From inside the hip joint, the psoas tendon is brought into view by making a small window in the hip capsule. The lengthening of the tight tendon begins first, followed by a cut to release it, which allows the tendon to fill in with scar tissue, ultimately resulting in its lengthening.
Acetabuloplasty (Rim Trimming/Decompression)
Anterior over-coverage secondary to a pincer lesion can be treated arthroscopically. This lesion is usually associated with a flattened, degenerative or cystic labrum. Pincer lesions require bony resection, which can be performed using a motorized burr. Resection of the rim lesion oftentimes leads to destabilization or requires detachment of the labrum in order to fully visualize the extra bone. Following the rim resection, unstable, but healthy, residual labral tissue is refixed to the acetabular rim using arthroscopic suture anchoring techniques.
Osteochondroplasty (CAM decompression)
With visualization of the CAM lesion, a motorized burr is introduced and the removal of the CAM lesion is performed to recreate a spherical femoral head. A resection of less than 30% of the head-neck junction is recommended to preserve the load-bearing capacity of the femoral neck, and therefore decrease the risk of a stress fracture. Fluoroscopy is often used to assist in determining the amount of bone in need of resection.
Hip Dysplasia Procedures
The femur is surgically reshaped and repositioned to restore a more normal anatomy. This allows for normal hip motion and alleviates the impingement. Some osteotomies can be performed via minimally-invasive procedures that use small incisions. An osteotomy that involves cutting the bone (usually an open procedure, not arthroscopic) is a technique where the anatomy of the femur or socket is altered to relieve pain and prolong survival of the joint by reducing the abnormal loads on the cartilage.
This is a procedure where the joint is opened to clean out bone spurs, loose bodies, tumors or to repair fractures.
Iliotibial Band (ITB) Release
An ITB release is performed on patients with symptomatic (painful) snaps. This is performed by accessing the lateral space in the hip. Once the ITB is visualized, a cut is made to lengthen the tissue.
A trochanteric bursectomy is a simple procedure in which a motorized shaver is placed in the peritrochanteric space (outside of the hip) to debride the inflamed bursal tissue.
Gluteus Medius Repair
In the majority of cases, the procedure is completed arthroscopically; however, the size and/or location of the tear may warrant an open procedure. The tendons are visualized and an anchor(s) is placed into the greater trochanter of the femur while a suture is passed around the tendon. The tendon is then pulled down to its normal anatomic position and tied over the bone. The procedure is very similar to that of a rotator cuff repair in the shoulder.
Hip Arthroscopy and Anesthesia
There are two options for anesthesia with arthroscopy: general or regional. Regional is the preferred option, as it allows for pain control immediately following surgery and tends to minimize anesthetic side effects including nausea, vomiting, pain at the site of insertion, etc. Some patients who have spine pathology or bleeding disorders may not be candidates for a regional block. In this case, general anesthesia is recommended.
In the majority of hip arthroscopy cases, when a regional anesthetic is used, a spinal block is used rather than an epidural. A spinal block and epidural differ both in where the medication is administered into the spine as well as in the duration of its effect. For long cases, which will require an anesthesiologist to continually dose a patient over time, an epidural is warranted. For cases when a procedure should not exceed three hours, a spinal block is typically adequate. An anesthesiologist speaks with each patient prior to a procedure in order to make sure the patient is adequately informed.
Crutch time varies, but is usually anywhere from 2-4 weeks. Gluteus medius repairs require 6 weeks on crutches, as does a microfracture procedure.
- Continuous Passive Motion (CPM) Machine
The CPM machine is a post-operative treatment method that is designed to aid recovery following joint surgery. For most recovering patients, attempts at independent joint motion causes pain and therefore the patient avoids moving the joint, which can lead to tissue stiffness around the joint and the formation of scar tissue. Ultimately, this may limit a patient’s range of motion and require physical therapy to restore the lost motion. The CPM machine moves the joint without the use of the patient’s muscles. The CPM machine is typically used for 4 hours/day for 4 weeks.
A brace is worn for 2 weeks following surgery to prevent extreme flexion and extension of the hip, and is only worn during weight bearing activities using crutches.
- Ice machine
The ice machine is to be used 4-6 times a day for 20-30 minutes at a time.