ARTHROSCOPIC SURGERY OF THE HIP - Indications based on the literature and our experience

A. Tzaveas 1, A. Papavasileiou 2
1. The Wellington Hospital, London, UK
2. St Luke’s Clinic, Panorama, Thessaloniki
Summary
Hip arthroscopy is a widely accepted and rapidly evolving surgical technique for numerous conditions of the hip joint. Its indications are continuously expanding. We present the current indications, the modern techniques and the results, based on the literature and our own experience.
Abstract
Hip arthroscopy is a universally accepted fast evolving surgical technique for numerous pathologies of hip joint. The indications are continuously expanding. We present the current indications, recent techniques and results based on literature review and our experience.
Introduction
For many years hip arthroscopy was considered an «exotic» operation. In 1931 Burman wrote that «it is manifestly impossible to place a needle between the femoral head and the acetabulum». The application of the arthroscopic technique to the hip lagged well behind the other large joints, because of the relative difficulty of access and the close proximity of the sciatic and lateral femoral cutaneous nerves, as well as other neighbouring neurovascular structures. The hip therefore received less attention, particularly in the field of sports medicine, with most symptomatic patients being labelled as cases of «early arthritis».
In recent years, however, improved diagnostic techniques such as magnetic resonance imaging with or without contrast have given a new dimension and have helped to detect conditions of the hip that were previously unrecognised. The design of new instruments, the new techniques of traction and distraction of the joint and better knowledge of the positioning of the patient and of the placement of the arthroscopic portals (Khanduja and Villar, 2006, Papavasileiou et al, 2008) have also led to wider use of the method.
This article sets out the indications for arthroscopic surgery of the hip, based on the recent literature and the authors’ experience.
Tear of the labrum
The function of the labrum lies in enhancing stability, maintaining the congruity of the joint and stabilising the adjacent articular cartilage (Ferguson et al, 2003). It has been proposed that the labrum is a continuation of the articular cartilage of the acetabulum (Seldes et al, 2001), so that tears of the labrum are to a large extent associated with chondral lesions. The commonest site of such a lesion is the area of the gradual transition from the labrum to the articular cartilage, the “watershed zone” (McCarthy et al, 2001). A lesion of the labrum at this point results in destabilisation of the adjacent articular cartilage, allowing joint fluid to pass beneath it. The cartilage then becomes detached from the subchondral bone, creating the earliest osteoarthritic lesion in the joint (Fig 1). Five causes of labral tears have been identified. These comprise trauma (Dameron, 1959), femoroacetabular impingement (Beck et al, 2005), capsular laxity (Philippon, 2001), dysplasia (Byrd and Jones, 2003) and degeneration (Kelly et al, 2005).
The aim of arthroscopic treatment of a labral tear is to remove its unstable flaps, by partial excision or by repair. The ultimate purpose is to eliminate pain, to restore the normal anatomy and to prevent damage to the articular cartilage of the acetabulum. Partial excision can be carried out with arthroscopic punches or a diathermy device, while the repair is performed with special arthroscopic sutures (Fig. 2) (Miller et al, 2009). Detachment of the labrum can be treated by re-fixation of the labrum with bone anchors.
Improvement of symptoms has been reported in 80% of patients after arthroscopic repair of a labral tear when there is no coexisting damage to the articular cartilage (Chiron, 2006). In a study by Espinosa et al (2006) a group of patients who underwent partial excision of the labrum was compared with a second group in which the authors carried out re-fixation of the labrum, and the results showed faster and better recovery in the second group at two years of follow-up. Another study by Bryan et al (2003), assessing 400 cases of arthroscopic treatment of a labral tear, showed encouraging medium-term results.
Femoroacetabular impingement
The concept of femoroacetabular impingement was first introduced by Murray (1965), while Stulberg et al (1975) were the first to describe the pistol-grip deformity of the proximal femur. Harris (1986) subsequently linked disorders of the hip in childhood and adolescence aetiologically with osteoarthritis in adult life. The theory of femoroacetabular impingement as a mechanical cause of osteoarthritis was, however, established by the work of Ito et al (2001) and Ganz et al (2003).
Femoroacetabular impingement is defined as the abnormal contact and abutment between the femoral head – neck junction and the rim of the acetabulum. This abnormal contact occurs in patients with abnormal morphology of the proximal femur and/ or of the acetabulum, or in individuals with normal morphology but an excessive range of movement of the joint. This morphology is usually (in up to 90% of cases in our experience) present in both hips. The contact is seen between the anterior / lateral part of the neck – femoral head junction, which impinges on the anterior rim of the acetabulum. This repeated abutment often leads to damage to the labrum and the articular cartilage.
Ganz et al (2003) described two distinct types of femoroacetabular impingement. Pincer-type impingement (impingement of the «pincers» or «clamp» type), which occurs as a result of anterior overcoverage of the acetabulum or of its marked anterior inclination, and cam-type impingement (impingement due to femoral hyperostosis), which occurs when there is loss of sphericity of the femoral head, which impinges on the anterior rim of the acetabulum, particularly during flexion and internal rotation of the hip, thereby exerting repeated compressive and, above all, shear loads at the junction of the labrum with the articular cartilage. The non-spherical femoral head is produced by structural abnormalities of the offset, usually described as a pistol-grip deformity of the femoral neck (Klaue et al, 1991). We believe that a mixed cam and pincer pathology usually coexists.
The aim of arthroscopic treatment is the removal of bone at the neck – head junction of the femur for cam-type impingement, and acetabuloplasty for pincer-type impingement, which restores the normal mechanics of the hip at the extremes of movement, together with simultaneous repair of the coexisting lesion of the labrum (Fig. 3) (Tzaveas and Villar, 2008). This eliminates the microtrauma at the anterior rim of the acetabulum and thus, potentially, slows the progression of osteoarthritis in young patients (Bare et al, 2005).
Stahelin et al (2008) studied the restoration of the femoral offset in 22 patients treated arthroscopically, examining imaging studies and the clinical outcome on the basis of outcome scales. They found that the femoral offset can be restored accurately by the arthroscopic technique in the treatment of the femoroacetabular impingement lesion. Larson et al (2008) reported their early results from arthroscopic excision of the femoroacetabular impingement lesion in 96 patients (100 hips). They found that 75% of the patients had good to excellent results with a minimum follow-up of one year. A recent study (Bardakos et al, 2008) compared the results of two groups of patients who had a femoroacetabular impingement lesion. The first group underwent excision of the lesion, while the second did not. The results were compared and a statistically significant difference was found in the improvement of symptoms, with better results in the group in which the impingement lesion was excised.
Lesions of the articular cartilage
Lesions of articular cartilage that has not yet become detached, such as chondral delamination progressing to frank separation, the formation of a free chondral flap and a subchondral cyst, are extremely difficult to detect with the available non – invasive techniques (magnetic resonance imaging) (Khanduja and Villar, 2006). Magnetic resonance imaging with contrast gives better visualisation of the labrum and particularly of the articular cartilage than plain magnetic resonance imaging, with a sensitivity and specificity of the order of 90% and 91% respectively (Czerny et al, 1996). Hip arthroscopy nevertheless remains the best diagnostic means of making the diagnosis.
The techniques available for treating these early chondral separations include «gluing» and / or smoothing with a radiofrequency probe or an arthroscopic shaver, while large, unstable flaps are excised and the microfracture technique is carried out on the subchondral bone (Fig. 4). A promising new technique is that of gluing the chondral flaps with fibrin (Tzaveas and Villar, 2009) (Fig. 5). The outcome of treating these lesions depends mainly on how early the diagnosis is made and on the extent of the lesion.
Unfortunately no studies on chondral lesions are available apart from a few with small case series. Philippon et al (2007) reported partial fill and restoration of the areas in which they had performed microfracture, in patients who underwent revision arthroscopy. In nine patients the cartilage fill reached 91% of the area after 20 months (range 25% to 100%). One patient with 25% fill of the area eventually underwent total hip arthroplasty 66 months after the initial operation.
McCarthy (2004) reported that the patients’ results depended directly on the stage or grade of the lesions of the labrum and of the articular cartilage, observing that labral tears were the commonest cause of mechanical symptoms in the hip. The tears occur in its anterior part and are usually combined with chondral lesions, and the severity of these chondral lesions is to a large extent related to the outcome of the operation. The most frequently observed chondral lesion is the one in the “watershed zone”, which consists of a tear of the labrum with its separation from the articular surface at the point where the labrum joins the articular cartilage. The author also stresses that the difficulty of detecting these lesions by conservative means and the importance of treating them for the final outcome justify performing hip arthroscopy.
Disorders of the synovium
Arthroscopy allows the diagnosis and treatment of conditions affecting the synovium such as villonodular synovitis, synovial chondromatosis, rheumatoid arthritis and the crystal deposition arthropathies (Krebs, 2003). As a diagnostic tool, arthroscopy allows a biopsy to be taken with great accuracy, after inspection of the most inflamed tissue (Eriksson et al, 1986). Therapeutically, synovectomy can be performed arthroscopically, together with removal of chondral and osteochondral loose bodies (Sekiya et al, 2000).
Boyer and Dorfmann (2008) recently published a series of 111 patients treated arthroscopically, with good and excellent results in the majority of patients.
Loose bodies
Loose bodies may be responsible for symptoms such as a sensation of locking or pain in the hip. The causative factor may be synovial osteochondromatosis, Perthes disease, osteochondritis dissecans or trauma (dislocation of the hip – Pimpkin fracture) (Krebs, 2003). Loose bodies are usually detected on radiographs when they contain calcium, whereas they may go unnoticed on magnetic resonance imaging (Potter et al, 1994). Mullis et al (2006) reported the presence of arthroscopically detectable intra-articular loose bodies in patients with a dislocation of the hip or a fracture of the acetabulum, conditions that would otherwise have been managed without an operation. The same authors, in a study of 36 patients, concluded that loose bodies are usually found within the joint after closed treatment of a dislocation of the hip or a fracture of the acetabulum, even if the radiographs are negative (Fig. 6).
Adhesive capsulitis of the hip
There are reports in the literature (McGrory and Endrizzi, 2000, Mont et al, 1999) of patients with adhesive capsulitis of the hip in whom symptoms of reduced movement and pain similar to those of adhesive capsulitis of the shoulder were observed. In these cases, and where conservative treatment has failed, arthroscopy may be considered as an alternative, although the results in the literature are not yet clear (Fig. 7).
Ligamentum teres
The function of the ligamentum teres has long been a controversial subject, the view that it is simply an anatomical remnant standing in opposition to those who argue for its significant biomechanical role in the hip joint (Bardakos and Villar, 2009). Hip arthroscopy has made it possible to recognise the ligamentum teres as a cause of pain and of mechanical symptoms in the hip, such as locking or instability (Fig. 8) (Rao et al, 2001, Byrd and Jones, 2004, Yamamoto et al, 2008). Tears of the ligamentum teres may be traumatic or degenerative. Philippon and Villar have reported arthroscopic reconstruction of the ligamentum teres with an iliotibial band graft in cadaveric specimens (Bardakos and Villar, 2009). In cases of a partial tear of the ligamentum teres we can carry out shrinkage of it with a flexible arthroscopic e-flex electrocautery device (Smith & Nephew Inc., Endoscopy Division, Andover, Massachusetts).
Osteonecrosis of the femoral head
Arthroscopy assists in the better assessment of lesions on the surface of the femoral head, as well as in the classification of the disease and in the treatment of coexisting intra-articular pathology (chondral lesions or loose bodies), and it also increases the accuracy of access to the affected area (Papavasileiou et al, 2009).
Septic arthritis
Treatment of septic arthritis of the hip requires thorough lavage and debridement of the joint. Arthroscopic lavage avoids the morbidity of an open operation, as it does in arthroscopic lavage of the knee (Bould et al, 1993). The technique also allows a biopsy / culture to be taken in doubtful cases (DeAngelis and Busconi, 2003).
Diagnostic value after hip arthroplasty
Hip arthroscopy can provide valuable information in doubtful cases of septic infection of a hip arthroplasty, by obtaining material for biopsy and culture, and also in cases of early loosening of the implants where a bone scan cannot give reliable information (Fig 9). Cases have been described of arthroscopic removal of loose bodies or debris from the area between the implants of a total hip arthroplasty (Vakili et al, 1980, Nordt et al, 1987).
Osteoarthritis
In selected cases arthroscopic intervention in osteoarthritis of the hip includes osteophytectomy, microfracture, removal of the loose bodies, excision of the femoroacetabular impingement lesion and shaving of the chondral flaps, together with a wide capsulotomy to increase the range of movement of the joint (Fig. 10) (Samspon, 2006). It may also be of great value in assessing the lesions in the young patient with an arthritic hip, in order to decide on definitive treatment, since it is well known that the radiological findings in osteoarthritis do not always correspond with those of arthroscopy (McCarthy and Lee, 2004). It should be stressed, however, that both the surgeon and the patient must have realistic goals in these cases.
Extra-articular conditions
In recent years there has also been considerable progress in the arthroscopic treatment of extra-articular causes of pain around the hip. Trochanteric bursitis (inflammation of the bursa of the greater trochanter) that does not settle with conservative measures is an indication for endoscopic surgery: through two arthroscopic portals on either side of the greater trochanter the bursa is inspected and excised (Wiese et al, 2004, Fox, 2002). Iliopsoas tendinitis may be a cause of pain, particularly in athletes: the tendon can be approached arthroscopically from the peripheral compartment, where a tenotomy or simply a release from the surrounding soft tissues is performed (Ilizaliturri, 2009) (Fig. 11). Snapping hip, due either to impingement of the iliopsoas on the iliopectineal eminence or on the femoral head, or to impingement of the iliotibial band or of the gluteus maximus on the greater trochanter, can now be treated arthroscopically, by division, lengthening or release from the surrounding soft tissues (Ilizaliturri et al, 2005) (Fig. 12).
Conclusions
Arthroscopy, as a new weapon in the hip surgeon’s armoury, complements the range of arthroscopic techniques for the large joints, having now been recognised as a highly successful operation. As the surgical instruments for hip arthroscopy develop and surgical experience grows, the ground is prepared for new expectations. The manufacture of new instruments of appropriate diameters and angles, of arthroscopic sutures, of bone anchors and of support devices has made possible operations that once required extensive surgical trauma. Arthroscopy also contributes to reducing morbidity and hospital stay, as well as to rapid rehabilitation of the patient. It opens new prospects for the design of biological procedures in the future, such as chondrocyte transplantation. It is, however, a specialised technique, with a long learning curve.
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Figure legends
Figure 1: Lesion of the labrum with associated detachment of the articular cartilage (arrow) (FH: femoral head, ACC: articular cartilage of the acetabulum, L: labrum) [authors’ archive]
Figure 2: Technique of labral repair with FastFix arthroscopic sutures (Smith & Nephew Inc., Endoscopy Division, Andover, Massachusetts). A: assessment of the lesion, B: introduction of the instrument carrying the sutures, C: final placement of the sutures, D: final result of the repair (FH: femoral head, L: labrum, ACC: articular cartilage of the acetabulum) [authors’ archive]
Figure 3: Femoroacetabular impingement lesion. (A: femoral hyperostosis (CAM), B: restoration of the normal anatomy after excision of the lesion, C: pincer-type lesion, D: appearance after acetabuloplasty (FH: femoral head, NFJ: neck – femoral junction, JC: joint capsule, AR: acetabular rim) [authors’ archive]
Figure 4: Microfracture technique in a chondral defect of the acetabulum (FH: femoral head, ACC: articular cartilage of the acetabulum) [authors’ archive]
Figure 5: Technique using fibrin (A: Assessment of the lesion – “wave sign”, B: injection of the fibrin through a needle, C: fixation of the chondral flap with an arthroscopic grasper, D: the appearance after the fibrin has set (FH: femoral head, L: labrum, ACC: articular cartilage of the acetabulum, JC: joint capsule) [authors’ archive]
Figure 6: Foreign body in the peripheral compartment of the acetabulum (arrow) (JC: joint capsule, L: labrum, FH: femoral head) [authors’ archive]
Figure 7: Adhesion of the joint capsule to the labrum: release with a diathermy device (FH: femoral head, JC: joint capsule, L: labrum) [authors’ archive]
Figure 8: Arthroscopic views of a lesion of the ligamentum teres. A: complete tear of the ligamentum teres after an injury, b: partial tear of the ligamentum teres (arrow) (FH: femoral head, AF: acetabular fossa) [authors’ archive]
Figure 9: Arthroscopic view of a hip resurfacing arthroplasty [authors’ archive]
Figure 10: Procedures on the osteoarthritic hip. A: removal of a central osteophyte, B: ossified labrum, C: after shaving (FH: femoral head, AF: acetabular fossa) [authors’ archive]
Figure 11: Arthroscopic views of the iliopsoas tendon after it has been exposed [authors’ archive]
Figure 12: Snapping hip. A: exposure of the iliotibial band, B: lengthening of the iliotibial band with a «Y» incision [authors’ archive]