Saturday, June 06, 2020

What is hip arthroscopy?

Like arthroscopy of the shoulder and knee, hip arthroscopy is where we use small instrumentation through tiny incisions around the hip joint to treat certain problems and sources of pain that previously required open surgery. Minimally invasive surgical approaches have allowed for the development of innovative techniques in many surgical fields, not the least of which is orthopedics, and over the last 20 years advances specifically in hip arthroscopy have come a long way.

My grandmother had a hip replacement for arthritis. What sort of problems can hip arthroscopy be used to treat?

It’s funny you mention that your grandmother had hip arthritis. Since orthopedic surgeons began treating patients with pain from hip arthritis with hip replacement, there was always a subset of patients noted to have arthritis of the hip that were becoming arthritic at a much younger age than would be expected. Whereas many patients who will require hip replacement become significantly symptomatic in their 60s and 70s, this other group of patients was developing x-ray evidence of arthritis decades earlier in their 40s and 50s. Their pain would ultimately still be addressed adequately with hip replacement surgery, but it’s not usually ideal to have one’s hip replaced so early in life. Starting 30 years ago, it began to be noticed that those folks needing hip replacement surgery at a younger age had actually been symptomatic for many years, sometimes with pain for the first time in their early 20s. And when their x-rays were looked at closely, it was noticed that even though they might not yet have full blown arthritis, they did present with subtle abnormalities regarding the alignment of their hip joints on these x-rays. For example, sometimes the hip joint socket looked deeper than it otherwise should and other times the orientation of the socket relative to the rest of the pelvis was facing slightly in the wrong direction. And yet other times it was seen that on the upper part of their thigh bones there was a boney bump at the ball of the hip joint that shouldn’t normally be there. The presence of these factors either alone (or more commonly in combination) can lead to impingement of the hip joint with motion, what we call femoroacetabular impingement or FAI. It’s this impingement that not only causes pain to be felt in the hip in certain extreme and ultimately not so extreme positions, but that, over time, can damage the soft tissues around the hip, and finally the hip joint cartilage, resulting in arthritis. The field of hip arthroscopy has therefore focused on addressing these predisposing malalignment issues so that advanced arthritis of the hip can be prevented and pain relieved.

That’s very interesting. What can actually be done arthroscopically to treat these hip alignment issues?

To figure out what’s exactly causing the pain, we may order an MRI of the hip in addition to taking x-rays. MRI can be helpful to see if there is a tear of the hip labrum as well as cartilage wear and tear that may be categorized as early arthritis. To get a better look at the boney alignment of the hip joint, sometimes a CAT scan is necessary. This information is utilized to formulate a plan to address all the possible malalignment causes of hip impingement pain the patient may have. Arthroscopically, we make anywhere from two to four incisions around the hip joint, and through these portals, we place a camera and instrumentation into the joint and first confirm the diagnoses suggested by the advanced imaging previously obtained. We then are able to address all the problems individually. If there’s a tear of the labrum, we can fix it and reshape the socket of the hip joint so that re-tear is less likely in the future. We can stabilize tears within the cartilage of the hip and can smooth out any bumps in the thigh bone that may be damaging the hip labrum and cartilage. Before the advent of hip arthroscopy, many of the problems mentioned above would have required an open surgical procedure where the hip joint would need to be dislocated and fully exposed to achieve these same surgical goals. Shoulder and knee arthroscopic surgical equipment is essentially identical but the development of hip arthroscopy required new innovative instrumentation to allow such minimally invasive surgery to be possible. For this reason, it’s an exciting, relatively new field.

What is the recovery like after arthroscopic hip surgery?

Ultimately this depends on what is done at the time of surgery. For example, if a labral repair is performed, the patient may be asked to avoid putting weight on the operative leg for a few weeks. By and large though, full recovery at three to six months is comparable to other arthroscopic procedures we commonly perform on the knee and shoulder.

Are there any other things patients should know about hip arthroscopy?

The key to a successful hip arthroscopy procedure, like any other surgery, is that the patient is a good candidate for the chosen surgical plan. For example, someone with advanced wear-and-tear arthritis is unlikely a good candidate to benefit from a hip arthroscopic procedure. They would be better suited with having hip replacement surgery. Great outcomes can be had when both the surgeon and patient are on the same page in terms of what the goals of the surgery are and what possible benefit to the patient can realistically be achieved. Being honest with the patient regarding this and therefore managing expectations appropriately is of utmost importance.

By Dr. Don Heitman

Dr. Heitman is board certified with the American Board of Orthopedic Surgery and is a fellow of the American Academy of Orthopedic Surgeons. He also maintains memberships in the Arthroscopy Association of North America and the American Orthopedic Society for Sports Medicine attending yearly conferences and surgical labs to stay abreast of the latest operative solutions and techniques. He holds medical licenses in the states of New York, New Jersey and California.