Hip arthroscopy is a surgical procedure where problems in the hip can be diagnosed and treated using keyhole surgery. This is usually performed by making 2, 3 or occasionally 4, 1cm incisions to pass a telescope and instruments to treat the underlying problem/s.
The hip joint is a ball and socket joint. The femoral head (ball) is on the upper end of the femur (thigh) bone and the acetabulum forms the socket part of the hip joint. Both the ball and the socket are covered by smooth articular cartilage. This articular cartilage is a highly specialised area allowing low friction and pain free range of motion. Damage to this cartilage surface leads to arthritis. The labrum is a specialised fibrocartilaginous region at the rim of the acetabulum. The labrum is an important structure that adds stability, as well as the ability to deepening the socket as well as providing important function to the nutrition of the hip and maintenance of joint fluid in the hip.
- Labral tears
- Treatment of femoroacetabular impingement (FAI)
- Removal of loose bodies
- Treatment of synovitis
- Synovial biopsy
- Treatment of hip joint infection with arthroscopic washout
- Diagnosis of unexplained hip pain
- Management of damaged hip ligaments (ligamentum teres)
- Investigation of a painful hip replacement or hip resurfacing prosthesis
- Semi advanced osteoarthritis
- Stiff hip
- Significant hip dysplasia
Hip arthroscopy is frequently performed under a general anaesthetic, however regional anaesthesia may be an adjunct.
Length of Hospital Stay
Usually the patient stays in overnight and is discharged the following day after review with
physiotherapy and if pain and swelling is under control. However, other factors that include distance from the hospital and other social factors will be taking into consideration by Mr Ma.
The hip is a ball and socket joint. This is a very big joint and is covered by strong, powerful muscles. In order to access the hip, the hip needs to be separated by 10 to 15mm. This is performed with traction. In order to apply traction a special boot is applied to the foot and a large padded bolster isplaced in the groin to allow the traction force to be applied. After antiseptic solution is placed on the skin, preoperative drapes are applied. With the aid of x-ray (fluoroscope) a small fine needle is then inserted into the hip joint. This helps to break the hip’s natural vacuum. Initially air is injected into the hip (air arthrogram) which helps to show the labarum and cartilage surface in order to avoid them. Local anaesthetic is injected into the skin and the hip joint. Using this guide wire the portal is then established and a telescope placed into the hip. Subsequent portals are then inserted under direct vision with the arthroscopy by initially placing a fine needle to ensure that no important structures are
damaged. The guide wires are then further placed and further dilated under direct vision to ensure no damage is done. A minimum of 2, but frequently 3 and occasionally 4 incisions may be used to access different parts of the hip. These usually range in length between 5 and 10mm.
With the telescope inside the hip, any damage or problems inside the hip can be visualised and confirmed, allowing appropriate treatment. The duration of the hip arthroscopy can range from 60 minutes to 2 hours, and occasionally longer than that, if there is substantial damage and work to be done. During surgery if any bone removal is performed (Cam resection or Pincer debridement) then the x-ray (fluoroscope) is further used to confirm the location of any instruments and how much bone resection is taken.
Traction to the leg is kept to a minimum if possible. Before the procedure is finished the operated leg is usually moved under direct visualisation of the arthroscope to ensure that no further bony catching is seen, and final x-ray is used to confirm any bony resection.
At the end of the procedure further anaesthetic is infiltrated into the joint and the hip portals. Other medications, such as cortisone or joint fluid substitutes may be injected into the hip joint to minimise pain or treat cartilage damage. The small holes are then closed with some fine stitches and a waterproof dressing is usually applied and reinforced with a bulky bandage which is left over night. The patient is then returned to the anaesthetic recovery bay and an ice pack is placed onto the side of the hip.
Post Operative Recovery
It is common after surgery to immediately feel some discomfort and swelling around the groin and side of the hip. It is expected that there will be some discomfort around the foot and ankle region from the traction boot, and also in the groin from the bolster required during foot traction. Swelling from the initial fluid usually subsides over the next few days to a week or so. The numbness and the discomfort in the foot and ankle, as well as the groin, usually recovers over the next few days to a few weeks. It frequently feel like saddle soreness after riding a bicycle for a long time. The ankle can feel like a sprained ankle. Occasionally it may linger for longer. It is very rare to be permanent. Most people stay in hospital overnight. On the next morning of the hospital stay you will be seen by a
physiotherapist where they will ensure that you are safe to walk, initially with crutches. The initial exercise program will be explained to you. The duration of the use of crutches will depend on the operative findings and the surgery performed. However, most patients will be weight bearing as tolerated and then weaned off crutches within the first 1 to 2 weeks as pain allows and when there is no residual limp. Initially 2 crutches will be used, then 1 crutch, then no crutches.
Mr Ma will usually see you the night of surgery or the following day to check on your progress and to initially discuss the operative findings. Frequently after a general anaesthetic you may forget or not recall the full discussion, and as a result at the 10 to 14 day mark he will go through the operative findings again. Mr Ma will review you in his private rooms at around 10 to 14 days to review the wound. Stitches at that stage will be removed and formal discussion of the operative findings will occur.
Postoperative physiotherapy will be tailored to the specific patient’s needs and in particular diagnosis and operative procedure. This will be guided by Mr Ma and your physiotherapist. Although a protocol is established, this is highly flexible and is tailored according to the patient’s progress and problem.
Mr Ma recommends time off work after hip arthroscopy. For most patients who work at desk jobs he recommends 2 weeks off work. For patients in more strenuous and more labour intensive type work,he recommends 6 weeks off work. This will vary from patient to patient.
Most patients will be feeling relatively comfortable and pain free around the 6 to 8 week mark. Depending on how the hip is feeling and any surrounding muscle tightness/tendinitis or spasms, gradual return to sport and other more strenuous activities will be planned around the 8 to 12 week mark. At around the 3 to 4 month mark, sports specific retraining and rehabilitation will commence with a view to return to potential competition between 4 to 6 months. Occasionally around the 6 to 8 week mark there may be a slight flare up of pain as the inflammation around the hip is still settling and the patients rehab and physical activity increase.
Any increasing pain can be treated with simple pain relief such as Paracetamol or Nurofen or other anti-inflammatory medications and the application of ice packs and/or heat packs at a later date. Occasionally, an injection of local anaesthetic and cortisone may need to be injected to calm the inflammation down.
After surgery the main aims of rehabilitation is to:
- Restore early range of motion in the hip.
- Restore and maintain stability in the hip, and to avoid flare up from discomfort coming from the major muscle groups, in particular, hip flexors, abductors and adductors.
- As pain and inflammation settle and range of motion and stability continue to improve, then further emphasis would be placed on increasing strength and endurance.
- Initially straight line movements are performed.
- Gentle rotational movements may be considered at approximately 6 to 8 weeks time and further increased.
- Return to work will depend on the type of work, but in general desk work and administrative duties 2 to 4 weeks, manual labour and more physical jobs 6 to 8 weeks, but occasionally 3 months depending on job requirements.
For the first 6 to 8 weeks it is important to avoid flaring up hip pain. You should avoid:
- Any prolonged standing or walking
- Sitting in low chairs
- Any heavy lifting
- Sleeping on the side may flare up pain and it is recommended to stay for as long as possible on your back. A pillow between the knees may assist if you must sleep on your side.
- Sitting in low chairs may aggravate hip pain, especially early on. If possible a height
adjustable chair (gas lift) would be advisable
- In the first 6 weeks to avoid hip flexion beyond 90o
Risk and Complications
All operations entail some risk. General risks of any operation related to general anaesthesia include:
- Very small risk of heart attack
- Very small risk of stroke
- Deep venous thrombosis/pulmonary embolus
These risks are very low with respect to hip arthroscopy.
Common side effects of hip arthroscopy related to traction include:
- Temporary numbness and discomfort around the groin and genital region and the foot and ankle region. This is directly related to the traction required for hip arthroscopy. This frequently lasts days to a few weeks, but occasionally can extend to 2 to 3 months. It is very rare to have permanent nerve damage/numbness related to traction.
Other potential complications related to traction and air pressure include:
- Pressure sores around the groin or foot and blistering.
- The risk of deep infection is approximately 1:4000 to 1:5000.
- There is a small risk related to portal placement with respect to nerve damage and numbness around the portal site.
Other reported but very rare complications include:
- Femoral fracture
- Impaired blood supply to the femoral head (osteonecrosis/avascular necrosis).
- Wound problems with superficial infection and delayed wound healing is possible.
- If the case is prolonged, fluid extravasation into the thigh and also peritoneum has been reported but is rare.
Other potential risks include:
- Increasing pain in the hip or aggravation of any degenerative change in the hip.
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