Hip arthroscopy is performed in patients with chronic hip pain. Patients may experience pain in a variety of different ways, including at rest, with activity, while trying to sleep, and with rotational or weight bearing activities. Because of this pain, they may need to restrict activities including sports and/or activities of daily living including walking, standing, driving, prolonged sitting, getting in and out of bed or a car, putting on shoes and socks, and/or rotating from one position to another. The majority of patients do not have an injury or trauma that contributed to the development of pain, but rather the pain starts gradually and without any specific incident. Other symptoms that may be reported include popping, clicking, or snapping.
Arthroscopic hip surgery may be performed for a number of diagnoses that contributed to chronic hip pain. These diagnoses include a labral (labrum) tear, focal areas of articular cartilage damage, ligamentum teres tears, synovitis or inflammation in the joint, and femoral acetabular impingement (FAI). During hip arthroscopy, small incisions are made in the skin (called portals), and a camera and instruments are passed through the small skin incisions in order to perform the work. Typically, the impingement is treated with arthroscopic burring of the bone to reshape it. The labrum is generally repaired but other options include reconstructions and debridements, which are much less commonly used.
The goal of arthroscopic hip surgery is to preserve the hip, also known as hip preservation. Patients undergoing hip arthroscopy must have good compliance with postoperative protocols including detailed guidelines for physical therapy.
Patients with arthritis are not candidates for arthroscopic hip surgery, although these patients may have labral tears; the outcomes of arthroscopic hip surgery in the setting of arthritis are significantly lower. Patients are screened for injury as well as for being candidates for surgery with both x-rays and MRIs.
FREQUENTLY ASKED QUESTIONS
Hip arthroscopy is a minimally invasive technique performed to treat damaged structures around the hip joint in an effort to preserve the hip joint. Access to the hip joint is limited by virtue of the fact that it is a constrained joint. In other words, the ball and socket are deep and there is a lot of contact area between the two. Because of this difficulty in accessing the joint, hip arthroscopy has developed more recently as compared to arthroscopic techniques for the treatment of other joints, such as the shoulder or knee. Also because of this limited access, a different set of cameras and instrumentation have been developed to treat damaged tissues in the hip. With advances in technique (such as labral repair), instrumentation, and outcome assessments, hip arthroscopy has become much more popular in the past 10 years.
There are 3 pillars of success related to hip arthroscopy:
1) The damage itself is important in predicting success. I like to use the analogy of a car. The difference between a car from 1995 or a car from 2020, as wear and tear and degeneration especially affect outcomes. An MRI, an X-ray, and sometimes a CT scan, help in making this determination, but important additional information can be noted at the time of surgery.
2) The quality of the surgery itself. The surgery is technically difficult, and experience does make a difference. Dr Carreira has performed approximately 2,500 hip arthroscopies.
3) A well-done recovery. All the details that are provided related to recovery can help to ensure success. Protecting the tissues during the first six weeks after surgery is especially important.
The most commonly treated conditions at the time of hip arthroscopy are labrum damage, femoral acetabular impingement including both CAM and Pincer types, articular cartilage damage, ligamentum teres tearing, removal of loose bodies floating around the hip joint, and inflammation (synovitis). Other less commonly treated conditions include some spine impingement and snapping of the hip.
The primary procedure performed at the time of hip arthroscopy is labral treatment, with labral repair performed in the vast majority of patients. During labral repair, the labrum is reattached to the edge of the hip socket. Labral debridement (trimming away some of the labrum near the tear) and labral reconstruction (replacing the damaged labrum with soft tissue) are infrequent options that are performed in a small number of patients based on findings at the time of surgery. Labral repair has demonstrated superior outcomes to labral debridement in a number of published studies. The treatment of femoral acetabular impingement, both CAM and Pincer types, may include trimming of the bone on one or both sides of the joint. Articular cartilage covers both the ball and socket of the hip joint. Damaged cartilage can be treated by shaving it down to a stable point or with a “microfracture” technique. The microfracture technique is used when patients have substantial articular cartilage injury. Small holes are created in the bone of the socket which stimulates cartilage to fill in the area of the defect. A CT (CAT) scan may be obtained in order to better assess the alignment of the bones of the hip joint to serve as a map for surgical treatment.
The amount of damage in the hip joint is the primary determinant for time of surgery. With Dr. Carreira’s extensive experience with hip arthroscopy (now numbering over 2,000 cases in 10 years of practice), his surgical times have decreased significantly. Currently, the duration of surgery may be as little as one hour or as much as three hours, depending on the complexity.
Traction is the procedure by which the hip is distracted, or separated, to aid in performing hip arthroscopy. Traction opens up space within the hip joint between the ball and the socket, giving Dr. Carreira more room within the joint to visualize and treat all relevant conditions. With hip arthroscopy, the hip is not dislocated as is routinely performed with open surgery. Risks with traction include nerve temporary injuries consisting of loss of sensation around the perianal region or down the lower extremity. Dr. Carreira studied a series of over 50 patients with hip arthroscopy and noted no permanent injuries related to hip arthroscopy. Injuries were infrequent and the majority resolved by 6-weeks after surgery.
For the first 2 weeks, patients use crutches and are touch-down weight bearing. These limitations mean that the foot/toe can touch the ground but only without supporting any weight. When microfracture has been performed, crutch use may extend up to 6 weeks after hip arthroscopy. From 2-6 weeks after surgery, patients are instructed to limit themselves to simple daily living activities: “Act like an old and frail grandmother.” For example, you are not to walk Disney World, participate in a parade, or shop for hours. The tissue is healing, especially during the first 6 weeks after surgery, and protecting the tissue during this time is essential for success. After 6 weeks, therapy significantly increases in terms of stress and strengthening. Return to full sport typically occurs between 3 and 6 months, with a gradual progression depending on pain, weight of the patient, level of demand, and age. Participation in physical therapy is essential for success.
“The recovery seems complex.” I hear this not infrequently. For this reason, I have created a detailed packet of information which guides patients during the recovery. It’s very helpful before surgery as well as after surgery as a reference for expectations and guidelines to optimize success.