M.P. Muldoon, M. D.Orthopedic Medical Group of San Diego

Hip joint is much less accessible than other jointsMore technically difficult-need specialized equipment and expertiseConditions warranting its use are rarerUse and indications are emerging

Minimally invasive means of seeing inside the hip joint without cutting muscles or using big incisions much like is done in the knee or shoulderFirst done in 1930s but re-introduced in late 1980s by Dr. Glick of San FranciscoTechniques and indications refined in mid-late 90s allowing more predictable resultsEven greater interest in last 4 years because of treatment of high profile athletes and improved techniques

IndicationsRemove loose bodies such as cartilage or bone from hip joint as on right

IndicationsInvestigate hip joint for sources of mechanical pain and address them surgicallyTo help diagnose hip pain sources when other test do not reveal source

IndicationsThe treatment of Femoral Acetabular ImpingementSnapping Hip SyndromesRecalcitrant Trochanteric Bursitis Repair or debridement of Labral tears

IndicationsAs an adjunct to other procedures in order to rule out problems inside the hip joint or allow other procedures to be performed less invasively

Contraindications (reasons not to do hip arthroscopy)Advanced arthritis Arthritis without mechanical symptoms (catching, locking)Very stiff hipsFresh fractures or dislocationsSurgical problems in which opening the hip joint is not necessaryObesitySometimes the instruments are not long enough

In order to view the hip joint without scuffing the cartilage it is necessary to use a traction device to open up the hip joint and allow instruments to be introducedGeneral or spinal anesthesia is preferred to allow for complete muscle relaxation

Special instruments have been designed to aid entry into hip joint and to remove damaged tissues

In Many cases surgery can be performed through two or three small incisions In lower picture patient is draped and flouroscopy unit in position to guide procedure

29 year old woman with pain and catching after intense period of exercise 8 months previouslyXrays were normal but the MRI arthrogram showed a tear in the labrum

At surgery a torn labrum was diagnosed and excisedPatient was back to full activities at 3 months

Surgery is generally done as outpatient but more complex surgeries with longer anesthetics may stay overnightThe hip is injected with long acting anesthetic to ease transition to home.Anti-inflammatories (NSAIDS) are prescribed for the first three weeks to aid in recovery with narcotics available for pain that does not respond to rest, ice and NSAIDS.In Many cases you will wake up with a motion machine - CPM which helps with pain and early mobilization

Crutches for several days to weeks until strength comes back Most patients can weight bear as toleratedMost severe pain is experienced in first 48-72 hrsSutures are removed at two to three weeksSense of fullness that persists up to 6-8 weeks

Pain at the incision sites is similar to a bruise in intensityActivity is progressed slowly with emphasis on low impact exercises for the first three monthsIn more complex cases for FAI - directed physiotherapy using a specialized rehabilitation protocol is employedComplete recovery may take 6-9 months

Temporary Nerve injuries can occur from traction on sciatic nerve or excess pressure from boot on top of foot. Most of these are markedly improved within a week but can last several weeks to monthsInfection or significant bleeding is extremely rare.Instruments can break in the hip joint and may require a bigger incision for removalThe surgery may not improve the condition and can occasionally make an arthritic hip worseHips can become stiffer and actually form bone in soft tissues known as Heterotopic ossificationthis can be prevented by use of NSAIDS for 3 weeks postop

SummaryHip arthroscopy provides a minimally invasive approach to dealing with many sources of hip pain that are unresponsive to other treatmentsThere is a low complication rate and a relatively rapid recovery after surgery