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

Hip joint is much less accessible than other joints

More technically difficult-need specialized equipment and expertise

Conditions warranting its use are rarer Use 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 shoulder

◦ First done in 1930s but re-introduced in late 1980s by Dr. Glick of San Francisco

◦ Techniques and indications refined in mid-late 90s allowing more predictable results

◦ Even greater interest in last 4 years because of treatment of high profile athletes and improved techniques

Indications◦ Remove loose

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

Indications◦ Investigate hip joint

for sources of mechanical pain and address them surgically

◦ To help diagnose hip pain sources when other test do not reveal source

Indications◦ The treatment of Femoral Acetabular

Impingement◦ Snapping Hip Syndromes◦ Recalcitrant Trochanteric Bursitis ◦ Repair or debridement of Labral tears

Indications◦ As 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 hips◦ Fresh fractures or dislocations◦ Surgical problems in which opening the hip joint

is not necessary◦ Obesity…Sometimes 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 introduced

General 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 previously

Xrays were normal but the MRI arthrogram showed a tear in the labrum

At surgery a torn labrum was diagnosed and excised

Patient was back to full activities at 3 months

Surgery is generally done as outpatient but more complex surgeries with longer anesthetics may stay overnight

The 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 tolerated

Most severe pain is experienced in first 48-72 hrs

Sutures are removed at two to three weeks

Sense of fullness that persists up to 6-8 weeks

Pain at the incision sites is similar to a bruise in intensity

Activity is progressed slowly with emphasis on low impact exercises for the first three months

In more complex cases for FAI - directed physiotherapy using a specialized rehabilitation protocol is employed

Complete 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 months

◦ Infection or significant bleeding is extremely rare.◦ Instruments can break in the hip joint and may

require a bigger incision for removal◦ The surgery may not improve the condition and can

occasionally make an arthritic hip worse◦ Hips can become stiffer and actually form bone in

soft tissues known as Heterotopic ossification…this can be prevented by use of NSAIDS for 3 weeks postop

Summary◦ Hip arthroscopy provides a minimally invasive

approach to dealing with many sources of hip pain that are unresponsive to other treatments

◦ There is a low complication rate and a relatively rapid recovery after surgery