Initial Experiences Of Arthroscopy Of The Hip

* Arthroscopy Unit,The Royal Orthopaedic Hospital Nhs Trust, Birmingham

Address for Correspondence:

J.Orthopaedics 2007;4(3)e9

Keywords:
Hip; Arthroscopy
Introduction:

Arthroscopy of the hip is now an established means for diagnosing and treating a variety of intra-articular pathology. It offers the benefits of being a minimal invasive procedure with short rehabilitation, minimal complications and allows for opportunities for future surgical interventions.¹ Better understanding of the arthroscopic anatomy, operative techniques and potential complications combined with proper patient selection have widened the scope for hip arthroscopy.

Our study was undertaken to look at indications, findings, complications and management outcomes from hip arthroscopy performed at our centre over a two year period. The aim of this paper is also to state the common indications, surgical methods, complications and post operative rehabilitation following hip scope.

Material and Methods :

A retrospective case series study was conducted at The Royal Orthopaedic Hospital, Birmingham involving all patients who underwent hip arthroscopy under the senior author (M.A.G). All the procedures were performed from April 2004 to Nov 2006 and were followed up for a minimum period of six weeks. A total of 35 hips were scoped in thirty five patients (15 male and 20 female). All the patients were assessed on basis of history of symptoms, physical examination and radiological investigations in the form of a CT scan or MRI scan. The average age was 32 years (range11-55 years). 18 right and 17 left hips were evaluated.

The procedure was done as a day case surgery under general anesthesia in all cases. Patients were positioned supine and a standard fracture table was used with the hip in

mild abduction and neutral rotation. A well padded lateral perineal post functioned as a fulcrum to aid in joint distraction. A 16G spinal needle, passed anteriorly, was utilised to break the vacuum under the image intensifier. Joint distraction of 5 to 10mm was obtained through traction on the extremity and confirmed on fluoroscopy. Standard antero-lateral and postero-lateral portals were then dilated over a guide wire and either a 30⁰ or 70⁰ arthroscope was introduced into the joint. Hip distraction was aided by distension with saline using a pump infusion system. Average duration of the procedure lasted 30-45 minutes and 20 ml of 0.5% Marcain was instilled into the joint and infiltrated along the portal sites. Patients were taken off the traction table immediately after and the perineum looked for any pressure sores.

Post operative rehabilitation allowed for full weight bearing with crutches as tolerated with advice about gentle range of movement exercises. Patients were discharged home the same day and an initial follow up appointment made for in six weeks. Complications and treatment outcomes were assessed during these and subsequent follow up visits.

Results :

The average age of our study population was 32 years, with the youngest being an 11 year old boy presenting with a post traumatic osteochondral loose body. The oldest subject was a 55 year lady with a degenerate hip. (Figure 1)

Figure 1.  Age and sex distribution of the study group

Apart from pain, clicking and snapping were the predominant symptoms. All the patients were clinically assessed, operated and followed up by the senior author (M.A.G), but, except for one patient, they all had been treated previously by one or more orthopedic surgeon. Preoperative imaging in the form of a CT scan (plain or contrast enhanced) or MRI scan was obtained in all patients.

A working diagnosis was established based on the clinical presentation and imaging findings. In seven patients neither a clinical nor a radiological diagnosis could be made and were diagnosed as idiopathic painful hip. Hip arthroscopy was carried out for removal of loose bodies in six patients, of which one was diagnosed as intra-articular osteochondroma. Of the rest, four were post traumatic and one in a perthetic hip. There were fifteen patients with a positive radiological signs which included labral fraying or tear (six patients), sub-chondral cysts or signal changes (six patients), two patients with synovitis and one patient with osteochondritis dessicans. Three patients underwent arthroscopic washout for an osteoarthritic hip. Diagnostic arthroscopy to asses the articular surfaces for planned pelvic and femoral osteotomies was the indication in four patients. (Figure 2)

Figure 2. Indications for Hip Arthroscopy

A standard procedure for performing hip scope, as described earlier, was adopted in all cases. Access to the joint was possible without fail in all hips. The duration of the procedure was from 30 to 45 minutes. In ten hips normal looking articular surfaces and labrum was observed. Ten hips showed degenerative changes of all grades as the predominant finding. The lesions were debrided to stable edges or drilled, followed by a washout. Four hips had removal of a solitary loose body and two had multiple loose fragments. Imaging studies in a 38 year old lady suggested osteochondroma of the femoral neck, which on arthroscopy showed multiple loose bodies, degenerate changes on acetabular side and synovitis. Histopathological study showed the loose bodies to be cartilaginous and a part of degenerative joint change.  Labral fraying or tear was seen in five hips, all of which were debrided and edges smoothened. In two hips, this finding was recorded in addition to degenerative changes of the acetabulum. Isolated cartilage change was noted in four hips. One was an osteochondritis dessicans lesion, which was drilled under image intensifier. (Figure 3)

                                    Figure 3. Predominant arthroscopic findings

No perineal or foot pressure sores were detected after surgery. 90% of our patients went home the same day.  No intra-operative or any major post-operative complications were identified. (Table 1) Traction neuropraxia was observed in two patients with paraesthesia in the leg and foot. Both were transient and resolved completely. One patient with dysplastic hip on whom diagnostic scope was performed had severe pain on mobility in the post-operative period which delayed discharge. Non-weight bearing for six weeks was the rehabilitation plan for a hip with micro-fracture for isolated osteoarthritic lesion.

Table 1: Complications

Of the study group, three patients did not turn up for their initial follow-up visit. Three fourths of the rest (24 patients) had a management plan at six weeks initial follow up and eight patients needed to be reviewed for a longer period. Fourteen patients were discharged with satisfactory outcome from our clinic. Eighteen patients were referred to other specialists for further treatment. Of these, data was available for sixteen cases. Nine patients went on to be operated or are awaiting surgical treatments like resurfacing arthroplasty, triple pelvic osteotomy or femoral de-rotation osteotomy. Four were managed non-operatively. One patient each was referred to the pain team for ongoing hip pain, spinal surgeons for back pain and for footwear modification for mild limb length inequality.  

Discussion :

Hip arthroscopy was first described by Burman in 1931 who had stated: "It is manifestly impossible to insert a needle between the head of the femur and the acetabulum".² The ball and socket nature of the joint, its natural intra-articular vacuum and surrounding neurovascular structures make insertion of the arthroscope difficult and fraught with danger. It was only in the 1980’s that hip arthroscopy gained recognition as a diagnostic and therapeutic procedure, to be performed only by the experts.

It cannot be overemphasized that proper patient selection is the key to a successful outcome. Pathology confined to the hip joint that is amenable to arthroscopic intervention and reasonable expectations of postoperative outcomes are the ideal selection criteria.

General anesthesia or regional spinal anesthesia is equally effective but adequate muscle relaxation is essential for joint distraction. The patient can be positioned supine or lateral decubitus position, the choice depending on surgeon preference.^{3, 4} We prefer supine approach for the simplicity of the patient positioning, avoiding the need for specialized distraction devices, familiar joint orientation and optimal access for all portal placements.

Commonest indications described in literature include diagnostic arthroscopy, removal of loose bodies, synovial biopsy, subtotal synovectomy, management of labral tears, synovial chondromatosis, osteochondritis dissecans, chondral lesions, and the treatment of septic arthritis.⁵ Contraindications to hip arthroscopy include systemic illness, superficial infection, arthrofibrosis or ankylosis, non-progressing avascular necrosis and morbid obesity. Patients aged above fifty five years and those with advanced degenerative arthritis do not respond well to hip arthroscopy and should be best avoided in them.⁶

Three patients were in the paediatric age group (under 16 years) in our study. Two boys had post traumatic loose bodies and one underwent arthroscopic assessment of the articular surface. None of the patients in our study were aged above 55 years .We did not encounter inability to access the hip in any patient, though this was found to be difficult in some.

Table 2. Pre-operative diagnosis and post operative findings

Overall arthroscopy altered the diagnosis in all but 11 patients. (Table 2) This did not include the four hips in which hip scope was performed to asses the articular surfaces. Even in this group, arthroscopy revealed degenerative changes in two hips and cartilaginous lesion in one hip. Of the seven patients with a working diagnosis of idiopathic painful hip, arthroscopy altered the diagnosis in four hips. The new diagnosis included osteoarthritis in 2, osteochondral lesion in 1 and labral fraying in one. Previous studies have shown the usefulness of diagnostic arthroscopy compared to MRI in reliably detecting chondral lesions and cartilaginous loose bodies.^{7, 8}  

In our study, a correlation between MRI result and arthroscopic finding regarding labral tear was seen in only one hip. Five patients with a labral lesion shown by imaging studies did not demonstrate the lesion on arthroscopy. One hip had labral fraying not detected by MRI. As Dorfmann et al have shown in their study, labral lesions were commonly overestimated at arthrography and only 18 lesions of 413 hips (4.4%) were confirmed on arthroscopy.⁹

 In the 24 hips with a preoperative diagnosis, arthroscopy revealed a different finding in 15 (62%). Of these, six patients had normal looking hips. The others with different diagnosis include osteoarthritis in 5, labral fraying in 2 and one osteochondral lsion.  One hip with preoperative imaging suggesting intra-articular osteochondroma showed multiple cartilaginous loose bodies, an outcome of advanced osteoarthritis.

Our study showed two nerve related complications with patients complaining of paraesthesia in the sciatic nerve distribution. Both of these were transient and made complete recovery. One patient had difficulty in mobilization during rehabilitation period and was discharged home on the third post-operative day. The reported complication rate in literature is between 0.5 to 5 %.¹¹ The commonest are traction neurapraxia, direct trauma to neurovascular structures, pressure sores, and largely unreported, iatrogenic joint damage. Rarer described complications include myositis ossificans, fluid extravasation, reflex sympathetic dystrophy, trochanteric bursitis, labial injury and instrument failure.

Post-operative rehabilitation protocols following hip arthroscopy is only recently coming into limelight. Rehabilitation protocols that have been typically used for surgeries such as total hip arthroplasty are often not sufficient for the population of patients undergoing arthroscopic procedures of the hip joint.¹² Postoperative rehabilitation can be staged into three phases under the supervision of the physical therapist. The initial phase in the first few weeks aims at restoring range of movements within tolerance and progressing on to full weight bearing. Weight bearing may be limited after some surgical procedures with a hip arthroscopy, including labral repair, iIliopsoas release, microfracture and capsulorraphy. The next few weeks comprise the intermediate phase, where the goal is to regain and build muscle strength. Finally the advanced phase involves improving the functional strength, endurance and stability with gradual return to sporting level activity as necessary.

Outcome measure studies have shown favourable results from hip arthroscopy in selected indications. O’Leary et al from 86 hips have shown best results in patients with labral injury, late Perthe’s disease, loose bodies or focal chondral defects and poor results in avasular necrosis and degenerative arthritis.¹³ They conclude that the presence of mechanical symptoms is a favorable prognostic factor for any diagnosis except degenerative arthritis. Byrd et al in their prospective analysis of 121 cases, have identified that patients with acute or traumatic onset of symptoms with greater improvement than those with insidious onset of symptoms and that longer duration of symptoms especially in male counterparts correlated with less successful outcomes.¹⁴ Greatest symptomatic improvement was noted in arthroscopic removal of loose bodies. The authors opine that hip arthroscopy can be performed for a variety of conditions (except end-stage avascular necrosis) with reasonable expectations of success. Baber et al have showed that arthroscopy revealed an abnormality in 81% of idiopathic painful hips and found a different abnormality in 30% of patients with a preoperative diagnosis.¹⁰ They report that arthroscopy aided in management in seventy four percentage of hips either by a change in the primary diagnosis in (53%) or by improvement of symptoms( 21%) Their study advocates the role of diagnostic arthroscopy especially with early cartilaginous lesions, labral tears and loose bodies.

Conclusion:

The role of hip arthroscopy in the management of hip disorders continues to expand with continued experience and improved instrumentation. It is now becoming increasing used for surgery to the structures surrounding the hip, not just to those within the hip cavity. Whatever the method, the most critical determinants for a successful outcome are patient selection and surgical expertise. Patients with mechanical symptoms and pathology confined to the hip joint and a reasonable expectation of the outcome are the ideal candidates for hip arthroscopy. Awareness of the potential complications, attention to patient positioning and proper orientation of portal sites is the surgeon factor that dictates good outcome.

Our study in the small, heterogenous group of patients with hip pain has shown hip arthroscopy to be a safe and effective means for assisting the management of hip disorders.

Reference :

1. Diulus CA, Krebs VE, Hanna G, Barsoum WK. Hip arthroscopy technique and indications. The Journal of Arthroplasty. 2006 June; 21(4 Suppl 1):68-73.

2. Burman MS. Arthroscopy or the direct visualisation of joints: an experimental cadaver study. Journal of Bone & Joint Surgery 1931; 8:669-95.

3. Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E. Hip arthroscopy by the lateral approach. Arthroscopy. 1987; 3(1):4-12.

4. Byrd JW. Hip arthroscopy utilizing the supine position.
   Arthroscopy. 1994 June; 10(3):275-80.

5. McCarthy JC, Busconi B. The role of hip arthroscopy in the diagnosis and treatment of hip disease. Orthopedics. 1995; 18:753-756.

6. Carreira D, Bush-Joseph CA.  Hip arthroscopy. Orthopedics. 2006 Jun; 29(6):517-23.

7. PalmerWE. MR. Arthrography of the Hip. Seminar in Musculoskeletal Radiology. 1998; 2(4):349-362.

8. Edwards DJ, Lomas D, Villar RN. Diagnosis of the painful hip by magnetic resonance imaging and arthroscopy. Journal of Bone & Joint Surgery Br. 1995 May; 77(3):374-6.

9. Dorfmann H, Boyer T. Arthroscopy of the Hip:  12 Years of Experience. Arthroscopy. Vol. 15, No. 1, 1999, 67-72.

10. Baber YF, Robinson AH, Villar RN. Is diagnostic arthroscopy of the hip worthwhile? A prospective review of 328 adults investigated for hip pain.Journal of Bone & Joint Surgery Br. 1999 Jul; 81(4):600-3.

11. Clarke MT , Arora A, Villar RN. Hip arthroscopy: Complications in 1054 cases. Clinical Orthopaedics and Related Research .2003 Jan; 406: 84-88.

12. Enseki KR, Martin RL, Draovitch P, Kelly BT, Philippon MJ, Schenker ML. The hip joint: arthroscopic procedures and postoperative rehabilitation. Journal of Orthopaedic and Sports Physical Therapy2006 Jul; 36(7):516-25

13. O'leary JA, Berend K, Vail TP.  The relationship between diagnosis and outcome in arthroscopy of the hip. Arthroscopy. 2001 Feb; 17(2):181-8.

14. Byrd JW, Jones KS. Prospective analysis of hip arthroscopy with 2-year follow-up. Arthroscopy. 2000 Sep; 16(6):578-87.

This is a peer reviewed paper 

Please cite as :Riazuddin Mohammed :Initial Experiences Of Arthroscopy Of The Hip

J.Orthopaedics 2007;4(3)e9

URL: http://www.jortho.org/2007/4/3/e9

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