Hip arthroscopy: a new method for treating hip joint disorders

Alexandros P. Tzaveas
Orthopaedic Surgeon
Hip arthroscopy is perhaps the most rapidly developing arthroscopic technique in orthopaedics and the most widely debated in the international literature. The reason is that, although it was first performed some 20 years ago, it was met with considerable scepticism by the scientific community and was regarded as a technique that was very difficult, if not impossible, to carry out. Advances in instrument technology, improvements in the techniques for entering the joint and the growing experience of surgeons have, however, led orthopaedic surgeons to use the method ever more widely. Long-term results in patients who had undergone hip arthroscopy, published recently in scientific journals, have also produced an "explosion" of interest in hip arthroscopy among orthopaedic surgeons worldwide.
Hip arthroscopy has come to complete the range of arthroscopic operations performed on the human body, arthroscopy having already been applied with great success to the knee, the shoulder, the ankle and the wrist. It offers all the well-known advantages of the arthroscopic technique: direct visualisation of the joint on a video monitor, high diagnostic accuracy, the ability to carry out a wide range of therapeutic procedures, a very small surgical wound, a short hospital stay and rapid mobilisation.
Potentially, candidates for arthroscopic hip surgery are all patients with pain in the hip or the groin lasting more than six weeks that does not settle with other conservative measures. Considerable care is nevertheless required on the surgeon's part, since patients with disorders of the bony part of the femoral head (necrosis of the femoral head, transient osteoporosis) or with very advanced osteoarthritis of the hip. The typical patient is aged 20-45, with a high level of sporting activity and groin pain related to physical activity.
There are two conditions in which arthroscopic treatment is most commonly used. The first is femoroacetabular impingement, in which the femoral head has an abnormal shape that causes it to move abnormally against the acetabulum and repeatedly injures the labrum of the acetabulum (the cartilage around the acetabulum) and subsequently the articular cartilage of the acetabulum (the cartilage that lines the acetabulum). This condition has in fact been implicated as a cause of arthritis, that is, of destruction of the articular cartilage. With the arthroscopic technique, bone is removed from the "abnormal" area with a dedicated instrument, in an attempt to restore the normal, spherical shape of the femoral head and, with it, to create the conditions for smooth movement of the joint.
The second condition is a tear of the acetabular labrum, which may be caused either by the femoroacetabular impingement described above or by a traumatic event involving a sudden, violent movement of the joint. At arthroscopy the labrum may show a large tear, a tear over a small area, or may appear degenerate. Depending on the case, it can be repaired arthroscopically (with dedicated arthroscopic sutures), partly removed (partial labral resection) or trimmed. The labrum may also be found detached from the bony rim of the acetabulum, in which case it can be reattached with dedicated bone anchors.
Other conditions that cause pain in the hip and are treated arthroscopically are isolated lesions of the articular cartilage, loose bodies within the joint (osteochondromatosis), disorders of the synovium, injuries of the ligamentum teres, septic arthritis (infection of the joint by a microbial agent), early osteoarthritis, iliopsoas tendinitis, trochanteric bursitis and snapping hip, while diagnostically it may be used in osteonecrosis of the femoral head and in painful hip arthroplasties.
The whole surgical technique is carried out through three small incisions on the outer side of the hip (1 cm each). One incision is used to introduce the camera, through which the image is transmitted, and the other two to introduce instruments. Both the camera and the other instruments are about the diameter of an ordinary pen. The operation lasts 1 to 2 hours.
Hip arthroscopy does not usually require a stay in the clinic, although in some cases the patient remains in hospital for a single night and is discharged the following day. After the operation there are three small surgical incisions on the outer side of the hip, each closed with a single suture. The surgical wound is therefore very small, which significantly reduces both morbidity and post-operative pain.
It should be stressed that post-operative rehabilitation is particularly important for the final outcome and should follow specific protocols, which it is advisable to observe scrupulously. The rehabilitation programme is based on intensive physiotherapy, chiefly exercise therapy, which begins one week after the operation and requires continuous supervision and guidance from a physiotherapist together with close cooperation with the surgeon. The patient follows a graduated programme of increasing intensity that gradually returns them to their normal level of physical activity. Hip arthroscopy is also a highly specialised surgical technique, carried out by specifically trained orthopaedic surgeons.
Hip arthroscopy opens new horizons in hip surgery and creates new prospects for operating on conditions regarded as incurable, difficult to treat or difficult to operate on because of technical challenges. We await the results from specialist centres abroad so that the further possibilities of hip arthroscopy can be assessed.