While knee and shoulder arthroscopy are the main methods of surgical treatment, hip arthroscopy has not been widely developed to date. In recent years with the improvement of surgical tools and techniques and mainly due to the better description of hip diseases in early stages for young patients, hip arthroscopy is gaining ground.
Hip arthroscopy is now used systematically to diagnose and treat various conditions in and around hip joints of young patients and athletes. Until now, these conditions would have been treated conservatively, interrupting any workout or sports activity until the time for total hip replacement.
Hip arthroscopy is probably not the solution for all hip problems. But it is possible to cure a wide variety of pathological conditions that have hitherto remained untreated.
Athletes strain their hip significantly, resulting in early degeneration of the articular cartilage of the hip joint. A significant proportion of lesions can be treated conservatively without major hip function problems, but some patients do not improve, a fact that leads in the need for surgical treatment.
Hip arthroscopy provides the benefits of any arthroscopic procedure, that is, the ability to perform complex operations through small incisions to the skin, thus significantly reducing morbidity and damage to healthy tissues caused by open surgery. Arthroscopy is a relatively simple and safe procedure that can be performed as a single-day operation without hospitalization for the patient.
Hip diseases cause several symptoms including:
- Nerve root pain, with possible reflection to the inner surface of the knee
- Joint movement inhibition
- Instability
- Acoustic effects
- Pain during rest periods or in certain movements or positions
- Stiffness
- Inability to walk or run
The main indications for hip arthroscopy are the following:
- Articular cartilage ruptures
- Loose bodies
- Impulse Syndrome
- Trochanteric bursitis
- Clicking sounds during hip movements
- Shortening of the iliopsoas muscle
- Rupture of the gluteus medius muscle
- Articular cartilage damage
- Rupture of the round ligament
- Osteoarthritis
- Rheumatoid arthritis
- Inflammation
- Undiagnosed hip pain
The success of the procedure depends largely on the experience and skill of the surgeon, but mainly on the correct selection of patients and the full investigation of the etiology of hip disease preoperatively.
It is reported that 60% of hip arthritis lesions that could be treated initially are diagnosed and treated improperly.
Anatomical Construction of the Hip
The hip joint is a spheroidal joint created by the round head of the femur fitted into the concave articular surface of the pelvis called acetabulum. The articulated bone surfaces are covered by a-few-mm-thick elastic tissue called the articular cartilage. The loss of articular cartilage after injury or degeneration of the joint leads into osteoarthritis.
The bones are surrounded by the synovial bursa and ligaments that hold them together, while the muscles that bridge the joint are responsible for the movement of the bones. An anatomical structure that is a frequent cause of symptoms is the rim of the articular cartilage, a circulatory fibrous film that surrounds the acetabulum.
Injury or damage to any anatomical component can cause significant symptoms to the patient and limit joint function.
Arthroscopically, the hip is divided into the central, lateral and distal compartments. The central compartment is the articular surface of the hip, the distal is the non-loaded surface anterior to the neck of the femur, and the lateral compartment is the peri-trochanteric space.
Surgical Technique
The purpose of arthroscopy is to insert in the hip joint a cylindrical camera with a diameter of 5 mm and various tools of the same diameter through another incision of corresponding size. The joint is filled with saline and the anatomical elements of the joint are examined with the camera. Depending on the problem, various surgical procedures can be performed.
The operation is performed under general or dorsal anesthesia with the patient in a supine position on the traction bed. The hip is initially stretched to increase the space between the femoral head and the acetabulum. Under an X-ray examination the hip is punctured and with the use of special tools the arthroscope enters the joint. With the help of the arthroscopic camera one or two more incisions are performed and other special tools are inserted in the joint; palpation of the joint follows, as well as repair or removal, if necessary, of various components that have been ruptured.
After 1-1.5 hours of operation, a local anesthetic is injected into the joint to avoid postoperative pain and the incisions are sutured. Thus, 2 or 3 incisions have been made of 5 mm each, which are stitched with a suture that is removed after 10 days.
During arthroscopy, a camera and various tools are placed inside the hip joint to perform various operations
Arthroscopic image of the normal hip
The normal rim cartilage
Degeneration of the rim cartilage
Rupture of the rim cartilage of the hip
Suturing of rim cartilage rupture
Risks of Hip Arthroscopy
Every surgery has theoretical risks, associated with both the anesthesia and the surgical technique. The probability of complications in hip arthroscopy is extremely low; however, if a complication that could not be predicted occurs, it is treated immediately and successfully. The most common problems are: inflammation, vein thrombosis, persistent pain and skin nerve injury in the hip area.
Immediate Postoperative Treatment
After surgery, the patient is transferred to the room where he/she remains bedridden for a few hours until total recovery. Then, under the supervision of a physiotherapist, the patient is mobilized by walking with the help of a walking cane, while he/he is taught specific exercises to support and strengthen hip muscles.
Many patients are discharged at night on the same day, while others remain hospitalized for 1 night and are discharged in the next morning with instructions and treatment.
Physiotherapy
The physiotherapeutic rehabilitation program depends on the problem for which the operation was performed and on the type of therapeutic intervention. Partial charging with a walking cane is usually recommended for 1-3 weeks and commencement of physiotherapy after 3-5 days. A specific exercise program is designed for each patient to practice at home.
Sleep
It is not recommended to sleep in a lateral position on the operated hip. Sleep in the supine position, or better still in the prone position, is recommended in order to extend the hip flexors.
Driving and Traveling
Driving is allowed progressively after 2-3 weeks. It is advisable to practice in an open parking lot earlier to make sure that you have control of the car and that the driving reflexes have returned. It is possible to travel immediately after surgery, even by plane, but it is advisable in this case to receive preventive anticoagulation agents.
Continuous Passive Motion Therapy (CPM, Continuous Passive Motion)
Postoperatively, it is recommended to use a passive kinesiology device for continuous hip training. The entire lower extremity is positioned in the device which continuously flexes and extends the lower extremity on the hip and knee joints. This avoids stiffness, while having a beneficial effect on the articular cartilage. It is recommended to use the device for 4-6 hours a day or 6-8 hours if there is damage to the articular cartilage.
Back to Work
Returning to work depends on the presence of post-operative pain, which is usually mild and the type of work. In office work, immediate return is possible, while heavy manual labor is preferable to be avoided and return should be considered after a full recovery in approximately 1-3 months. Compliance with the physiotherapy program and continuous practice at home should be ensured at all times.
