Hip arthroscopy is a surgical procedure where an arthroscope (4 mm camera) is inserted into the hip to allow for excellent visualization and management of hip injury and conditions.
The patient is positioned on the operating table and anesthesia is given. Traction is applied to the patient’s leg until 2 cm of space is created between the ball (femoral head) and the socket (acetabulum) allowing the insertion of instruments to proceed without damage to the surrounding joint. Two or Three puncture holes about 1 cm in size are generally needed to perform the surgery. Small instruments such as graspers, shavers and burs are introduced through these puncture hole to work on the various tissues in the hip joint. An X-ray machine called a fluoroscope (or C-arm) is used throughout the case to help gain access to the hip joint and to monitor the progress of the reshaping of the bone.
Hip arthroscopy typically takes between 1.5 to 2.5 hours to complete and is a complex arthroscopic procedure. During the procedure, the hip labrum can be repaired, debrided or reconstructed, loose bodies can be removed, and bony prominences (such as cam or pincer lesions) can be reshaped. The patient is typically able to go home on the same day as surgery and is on crutches between 2-6 weeks postoperatively. A physiotherapy protocol is provided by your surgeon and is typically begun within a week of surgery.
Hip arthroscopy is a challenging procedure and the best outcomes from surgery are obtained by sub-specialty trained, high volume surgeons.
What treatments for FAI and labral tears are available?
If a period of rest followed by rehabilitation and alteration of aggravating activities does not result in improvement of symptoms, then surgery can be considered. The labral tear is typically managed with a repair. Frayed edges of the labrum are debrided (cleaned to a stable base), and the edge of the socket (acetabulum) is likewise prepared using small shavers and burs. Small anchors are inserted into the edge of the socket and a strong suture is placed around or through the labrum securing it back to the bone.
It is rare that an isolated labral tear is the main problem and cause of the pain. The reason for the labral tear should be addressed. Typically, this is present due to FAI and the surgeon should treat the cam and/or pincer impingement to treat the pain and prevent recurrence of the labral tear. This is done by reshaping the abnormal bony anatomy to a more normal shape using the arthroscopic instruments.
Does arthroscopic surgery work?
Success rates in the published literature, in appropriately selected patients show that 80 to 90% of patients experience a substantial improvement in pain and most are able to return to sports. However, age and presence of arthritis are poor prognostic factors in patient improvement and hence these patients may not be optimal candidates for hip arthroscopy. We do not know what the long-term effect of hip arthroscopy will be on the hip. We are hopeful that having early repair of abnormal hip anatomy in symptomatic patients may prevent or curb hip arthritis in the future. Current research is underway to answer this question. However, as of now, performing surgery in patients with abnormal hip anatomy without pain or other symptoms is not advised. Hence, if an imaging finding reveals bony abnormality, it should always be interpreted in the context of the patient’s symptoms and if there are none, then surgery is not advised.
What kind of pain can I expect after the operation?
The patient can go home the same day and can often partially weight bear immediately with crutches. Patients use crutches for between 2-6 weeks depending on the type of surgery they have had and until they can walk without a limp. One to 2 weeks off for sedentary/desk-type work is likely required. If the job is physically demanding (such as a construction work or builder), 3-6 months off work may be required.
Physiotherapy is necessary in the postoperative period. Using a stationary bicycle is an excellent form of early rehabilitation and can be started as early as 1-3 days post-operatively. Your physiotherapist can guide you with exercises to strengthen the hip and core (abdominal and back) muscles as well as a stretching program. Time back to sports is more commonly 5-6 months.
How painful the postoperative period is for each patient depends on the surgery involved and the patient’s response to pain. Everyone is different. Having said that, after the first few days most people are relatively comfortable.
Will I need strong pain relief?
Narcotic analgesics are prescribed and may be needed for the first few days postoperatively. After that anti-inflammatory medication prescribed is often sufficient.
Will I be able to run or play sports again?
Generally, patients can return to sports without issues. The damage in some patients is significant enough at the time of surgery that impact activities, such as running, may not be advisable after a hip operation. If this is suggested, it is an attempt to prolong symptom free function and avoid further degeneration of the hip.
Will this surgery stop osteoarthrosis and the future need for a hip replacement?
Hip preservation surgeons certainly hope that by changing the abnormal anatomy of the hip to avoid repetitive damage to the joint surface the risk of arthritis may be diminished. However, no data is available to support these claims currently. Scientific evidence remains several years away with regards to arthritis prevention.
What are the potential complications?
Fortunately, complications are few and are listed as follows:
Operation day complications:
Traction injuries: The traction boot can cause pressure areas on the ankle or the heel. Perineal injuries have been reported when a padded post is placed along the perineum/groin and is used to help with traction. Surgeons at the VHI typically do not employ a post in the groin which eliminates the risk of these injuries.
Numbness to the thigh: There is a nerve that runs close to the incisions that are made around the hip for hip arthroscopy. Its sole function is to give sensation to the skin of the thigh. Branches of this nerve can be stretched or irritated during hip arthroscopy. Most often if there is some numbness it resolves on its own in the first few days or weeks after surgery.
Anaesthetic complications: In a healthy person a modern general anaesthetic is very safe. Situations such as adverse reactions to drugs or airway issues can be serious but fortunately are very unusual.
Infection: Infections are exceedingly rare after arthroscopic surgery of any joint because so much fluid is washed through the joint during the procedure. The wound will drain some clear to bloody looking fluid over the first few days. Pink solution that is used to clean the skin at the time of surgery can sometimes be confused with redness. Increasing discharge after the first few days, foul smelling discharge, fevers and sweats or increasing hip pain are some of the signs of infection that should alert the patient to seek urgent medical treatment.
Blood Clot (Deep Vein Thrombosis [DVT]): After any lower extremity surgery the patient is at risk of developing a blood clot in the large veins of their leg. It is unusual after hip arthroscopy but still may present in approximately 2% of patients. The signs of a blood clot include a warm, swollen painful calf. The blood clot can move to the lungs causing a pulmonary embolism. This may cause the patient to become extremely sick and in rare cases, can be fatal. This is a rare complication of any surgery of the leg but one that patients should be aware of. If a DVT is suspected, an ultrasound can be ordered.
Stress fracture: By removing bone from the femoral neck, theoretically the femoral neck is weakened. Returning to impact activities too quickly can put the patient at risk for a stress fracture. Even when crutches are not needed a return to impact activities should not occur prior to 10-12 weeks.
Avascular necrosis of the femoral head: This is perhaps the worst complication to the hip joint but fortunately is extremely rare. At the time of arthroscopic surgery great care is taken to avoid the blood vessels that supply blood to the ball (femoral head). Disruption of the blood supply to the femoral head often leads to death of that part of the bone and often necessitates a hip replacement. There have only been a few cases of this complication reported in the scientific literature out of the tens of thousands of hip arthroscopic procedures that have been performed around the world.
Adhesive capsulitis: In the postoperative period patients can get a stiff hip because of the inflammation associated with healing. This usually manifests sometime between 8-12 weeks post-operatively. The healing capsule becomes thick, tight, and inflamed. The patient feels as though they are making good progress but then gradually the hip becomes more restricted and painful. A cortisone injection into the hip may help relieve the symptoms if indeed adhesive capsulitis occurs.
Abdominal compartment syndrome: This is the rarest but severe complication following hip arthroscopy. Only case reports have been described in the orthopaedic literature around the world. It occurs when the fluid used to perform the surgery in the hip leaks into the abdominal cavity creating significant pressure that may require further surgery to open the abdomen to decompress the pressure.
The above list is not comprehensive but serves as a guide to some of the risks of this or any surgery. Hip arthroscopy is very safe but being well informed about the surgery can help in a patient’s recovery and improve the anxiety around an operation.
After reading this information guide, if any questions or concerns arise, please make an appointment to discuss these concerns prior to your surgery.