Keyhole or arthroscopic joint surgery has revolutionized orthopaedic practice, especially when it comes to joint related surgery. The most common joints involved are the knee and shoulder.
In contrast the development of hip joint arthroscopy has lagged somewhat behind the previously mentioned joints. This is due to the fact that the hip joint is very deep and constrained. As a consequence, in the past many problems related to hip joints have required large open surgical procedures with long recovery times.
Fortunately the skills and instrumentation have developed to a point where we are now able to perform hip arthroscopic procedures successfully, resulting in good recovery in a shorter space of time. Hence, we are able to avoid large open surgery and substitute this for a few small puncture wounds which allow entrance of the arthroscope and specialized instrumentation. Hip joint arthroscopy has also afforded us the chance to manage some hip joint problems which studies have shown may lead to early wear and tear osteoarthritis. These hip joint problems which often occur during sporting and /or traumatic events may now be managed through keyhole surgery and hopefully prevent the early onset of wear and tear arthritis. There are many other indications for hip joint arthroscopy aimed at relieving pain and suffering.
In most cases hip arthroscopy is a day case surgery with a minimal stay in hospital. Following surgery the services of a physiotherapist are invariably required.
Basic hip joint anatomy
Inidications For Hip Arthroscopy:
The following are possible reasons for having a hip arthroscopic procedure:
- Diagnostic reasons
- Labral tears
- Torn ligamentum teres
- Loose bodies
- Torn cartilage
- Buying time
In a number of cases a patient may present with pain related to the hip joint and following physical examination together with special investigations which include routine x-rays with or without CT scans and/or MRI scans, the surgeon is still unable to make a conclusive diagnosis. Often the patient has undergone a course of physiotherapy but the hip joint pain and/or discomfort is persistent and not relieved by conservative measures. In these cases, hip joint arthroscopy has proved an invaluable tool to aid in diagnosis of a joint problem. One can not substitute for the ability to be able to look directly at the source of problems in order to come to an answer. More often than not the diagnostic scope can be followed by therapeutic intervention with specialized instruments and so doing avoid large open surgery.
- Labral tear:
The labrum is a cuff of tissue which surrounds the cup of the hip joint and by so doing deepens the cup and forms a tight seal around the head of the thigh bone which contributes to the ball and socket type hip joint. This labral seal results in a suction affect which assists in stabilization of the hip joint as well as sealing in a layer of joint fluid which allows near frictionless movement. Labral tears therefore will affect this mechanism and can not only result in hip pain but it is felt in the long term can accelerate wear and tear arthritis. In many cases, labral tears may be addressed by arthroscopic hip joint surgery which will afford an opportunity to debride or smooth out rough torn edges of the labrum and/or deform a suture repair of the labrum depending on the extent of damage. The idea is to restore normal anatomy and thereby treat painful symptoms as well as prevent early onset of wear and tear arthritis.
- Torn ligamentum teres:
The ligamentum teres is a vestigial ligamentous structure which connects the head (or ball) to the socket of the hip joint. This structure can often be torn either subsequent to a traumatic event resulting in a wrenching of the hip joint, or a dislocation. Sporting activities which involve extreme limb positions such as kick-boxing and other martial arts as well as ballet and gymnastics, may often result in a torn ligamentum teres. This can sometimes result in pain and discomfort with associated clicking of the hip. Once again, arthroscopic surgery allows us to deal with this problem without the need for large open surgical procedures and risky dislocation of the ball and socket joint in order to access this ligament.
- Loose bodies:
In patient’s with early wear and tear arthritis or sometimes following trauma, sometimes a piece of cartilage may break off the moving surfaces. This can result in the formation of what is known as loose bodies. These bits of tissue will cause pain and catching symptoms in the hip and can result in further damage to the rest of the joint. Keyhole surgery affords one the ability to remove these loose bits via small incisions with rapid recovery after surgery.
Synovium is the tissue in all our joints that produces the lubrication fluid for joint movement. In, for example, patient’s with rheumatoid arthritis, this synovial membrane often becomes excessively inflamed. This results in the typical symptoms of pain and stiffness in affected joints. Arthroscopic surgery affords one the ability to remove almost all the synovium which will ultimately delay damage to the joint and also relieve symptoms related to the inflamed synovium. This surgery was often not done before in the hip joint due to the large surgical exposure required but arthroscopic surgery now allows us the ability to deal with inflamed synovium with minimal damage to the surrounding tissues and this is of great benefit to the patient.
In rare cases there are certain benign tumours which originate from the aforementioned synovial membrane and results in the formation of many calcified loose bodies within a joint or simply the synovium proliferates to such an extent that it obstructs joint movement and is also associated with pain. Arthroscopic surgery allows for resection of these tumours without the need for large skin wounds and potential damage to surrounding muscle and tissue. Should the diagnosis of a tumour be in question then a biopsy may be taken arthroscopically and sent to the laboratory for histological (tissue) diagnosis. This would then be a diagnostic arthroscopy which would in all likelihood be followed by therapeutic arthroscopic intervention.
- Torn cartilage:
A torn hip joint cartilage is often secondary to traumatic event either sporting or otherwise. In the past this was treated mainly conservatively and often may result in early wear and tear arthritis. Hip arthroscopy allows surgeons to address the problem area so as to alleviate painful symptoms and optimize the mechanical function of the joint once again.
There are some patient’s that are born with mild abnormalities of the socket orientation and/or they develop during childhood problems with the area of growth just below the head of the thigh bone. This results in a problem of impingement between the neck of the thigh bone and the socket edge. This can cause damage to the previously mentioned labrum and it is felt by many can consequently lead to earlier osteo-(wear and tear) arthritis. There are arthroscopic techniques which enable us to recreate the thigh bone head and neck off set which will allow better range of movement and prevent impingement. This sort of surgery is fairly technically demanding but there are indications that it is certainly worthwhile in preventing long term arthritis.
Infection in a joint is more typically found in children and in patient’s who are compromised in terms of their immune system. Infection essentially translates to puss within the joint space and this will result in a rapid destruction of cartilage. It is for this reason that surgery is urgently required in order to wash out the joint as soon as the diagnosis is made, to allow therefore healing while preventing further damage to cartilage. Previously this procedure was preformed with a large incision in order to facilitate drainage. Now, it can be done through small incisions and the use of an arthroscope.
- Buying time:
On occasion a patient with early wear and tear arthritis may develop mechanical symptoms such as clicking of the hip with associated pain. In this scenario a washout of the joint by means of an arthroscope may be useful in allowing one to continue to function reasonably well with the arthritic hip and thereby buy a few years prior to requiring a total hip replacement or resurfacing. Arthroscopic hip joint surgery allows surgeons to perform this joint debridement with minimal invasion and a quick recovery.
Hip arthroscopy with instruments
Hip Arthroscopic Surgery:
Once it has been determined that you are a candidate for hip arthroscopic surgery, you will be taken through the process of admission and on occasion there may be the need for pre-operative special investigations depending on your background physical status. Following admission to the hospital, you will be made comfortable in the ward and then transferred to the receiving room in the theatre suite. In the interim you will have met your anaesthetist who will go through the anaesthetic procedure required for hip arthroscopy. This may take the form of spinal or epidural anaesthesia together with light sedation or a full general anaesthetic.
You will then be transferred to the actual theatre and placed on the operating table which is designed to provide traction on the leg to be operated on. You will be given intravenous antibiotics to guard against infection. The leg that is to be scoped will be draped so as to isolate the hip joint and leg and thereafter treated with an antiseptic solution. The rest of the body is covered. Using x-ray guidance, the appropriate small surgical incisions for passage of the arthroscope and fine instrumentation, will be made. The inside of your hip joint will be examined thoroughly and appropriate pictures taken. Thereafter the diagnosed problem will be dealt with as appropriate. Following removal of all instrumentation, the wounds will be closed with small sutures and appropriate dressings. Depending on the nature of the intervention, this procedure can take anything from thirty minutes to two hours. After surgery you will be transferred to the recovery room where your vital signs will be monitored while you are recovering from the anaesthesia. Once the anaesthesia has worn off and you are able to eat and drink comfortably, arrangements will be made for discharge back home. Usually this may either be the same day or the following morning.
The beauty of arthroscopic surgery is that post-operative recovery is usually quite quick and the fact that the incisions are no more than 1cm in length results in a quick healing process. Nonetheless your hip will experience some discomfort and often a pair of crutches are required for mobilization while only placing half your body weight on the affected side. This, usually lasts for between three and four days but may persist for as long as two weeks depending on the procedure performed, there may be certain restrictions in terms of range of allowable movement at the hip so as to allow any repairs to consolidate before moving on to regaining full range of movement and muscle strength around the hip joint. Naturally this will entail a period of physiotherapy rehabilitation.
In most cases early movements is encouraged and you would use comfort as your guide. Full recovery may take as long as six to twelve weeks depending on the nature of the problem. The wounds are considered waterproof so as to allow normal bathing at approximately ten days following surgery. In most cases the sutures are absorbable and placed underneath the skin.
Hip arthroscopy (keyhole surgery) is a very valuable tool allowing orthopaedic surgeons to deal with many problems afflicting the hip joint without the need for large incision invasive surgery. It also affords us the opportunity to hopefully prevent early onset wear and tear arthritis by means of minimally invasive procedures that allow quick post-operative recovery. It remains the gold standard in terms of diagnosis of difficult hip problems. It remains a technically demanding procedure and many of the indications for hip arthroscopic surgery are still under review, however for the most part one can expect and excellent result following surgery.