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Advances in hip arthroscopy

Mr Sam Oussedik and Mr Fares Haddad look at a technique that is having a renaissance

Mr Sam Oussedik and Mr Fares Haddad look at a technique that is having a renaissance

Case history

A 28-year-old accountant presented to his GP during a busy Monday morning surgery complaining of right hip pain. He is a keen amateur rugby player, representing his local side on the wing. Six weeks ago he was playing in a competitive match when he was tackled, and in the ensuing ruck he received a blow to his right thigh with the leg in extension. Since then he has been experiencing discomfort in the groin and anterior thigh, activity-related pain that does not settle with rest, and occasional 'clicking'. He has been able to weight bear throughout.

Diagnosis and management

On examination he has an abnormal gait, favouring the left leg to counteract the pain. There was a reduced range of motion of the right hip compared to the left. Passive movement beyond the active range was painful. No palpable tenderness was elicited. Forcing the extended hip into internal rotation in the supine position while applying an axial load provoked clicking of the hip. X-rays were unremarkable but an MRI arthrogram confirmed an anterior labral tear. A hip arthroscopy (see box below) was undertaken and debridement of the torn labrum allowed a return to full function in eight weeks.

Sources of intra-articular abnormality should be investigated in patients with unremitting joint pain lasting longer than four weeks. In this case, a diagnosis of 'muscle strain or sprain' is clearly not sufficient. Assessment of hip pain is complicated by the number of disorders that can present in this way. An adequate assessment must therefore include direct questioning for possible symptoms, and examination of the back, pelvis and abdomen.

The history of trauma in this case gives an indication that a musculoskeletal cause around the hip is the most likely diagnosis. Examination should include:

  • assessment of the contra-lateral side for comparison
  • assessment of the ipsilateral knee
  • Thomas test for fixed flexion
  • FABER test ­ Flexion, Abduction, and External Rotation
  • mechanical impingement tests ­ see above
  • neurovascular examination of both legs
  • X-rays ­ plain anterior-posterior pelvic and lateral hip views.

Further assessment with bone scan, ultrasound, CT or MRI/MRI arthrography may be necessary to reach a diagnosis. Initial treatment of rest, ambulatory support, NSAIDs and physiotherapy may suffice for the majority of patients.

Differential diagnoses

Articular causes include:

  • stress reaction or fractures
  • hip dislocation/subluxation
  • femoral, pelvic and acetabular fractures
  • labral tears
  • osteonecrosis of the femoral head
  • cartilaginous injuries or degeneration.

Soft tissue causes include:

  • bursitis
  • snapping iliopsoas or iliotibial band
  • contusion
  • myotendinous strains
  • pyriformis syndrome
  • myositis ossificans
  • inguinal and femoral herniae
  • neurological irritation
  • hamstring syndrome

Fares Haddad is a consultant orthopaedic surgeon. He is clinical director at University College London Hospitals. Sam Oussedik is a research and clinical fellow at university college hospital London. Competing interests none declared

Hip arthroscopy ­ The Procedure

Hip arthroscopy was first introduced in the 1930s, but fell out of favour until it was repopularised in the late 1970s when advances in technique and equipment led to improved safety and efficacy. Hip arthroscopy is now being used to diagnose and treat conditions that have hitherto gone undiagnosed and untreated. It is available on the NHS and costs approximately £4,000 to have the procedure done privately.

Indications include:

  • Labral tears
  • Capsular laxity with iliofemoral ligament deficiency
  • Lateral impact injury
  • Chondral injury
  • Ligamentum teres injury
  • Snapping bands
  • Loose bodies
  • Synovial chondromatosis
  • Crystalline arthropathy
  • Infection
  • Posttraumatic debris
  • Osteoarthritis

Treatment of osteonecrosis of the femoral head

Diagnostic procedure in the presence of persistent symptoms with questionable radiographic evidence.Labral tears have a low healing potential but left untreated they may contribute to the progression of chondral degeneration. Treatment via arthroscopic debridement is associated with a 90 per cent good or excellent result. Postoperative instructions should include a range of motion exercises four hours post- operatively, followed by rotation precautions for a further 18-21 days.

No straight leg-raising should be allowed for four weeks. Capsular laxity of the hip is much less common than in the shoulder, as the hip is less reliant on soft tissues for its stability. However, any deviation from the normal bony anatomy can greatly increase this reliance, and lead to instability. This may be traumatic or atraumatic.

Treatment by arthroscopic thermal capsulorrhaphy can be effective. Chondral lesions in the hip can be an elusive cause of hip pain. They result from impact loading across the joint, such as a lateral impact injury. Symptoms of pain are usually of immediate onset. The presence of persistent symptoms together with positive examination findings should lead to further investigation. Chondral defects may require arthroscopy for diagnosis.

At arthroscopy the lesion can then be staged and unstable flaps debrided. The role of ligamentum teres within the hip joint is not well understood. It may well have a stabilising function. Tears are graded into complete (grade I), partial (II) and degenerate ligament (III). Treatment is by arthroscopic debridement.

The snapping hip can be subdivided into:

  • External or lateral ­ caused by an iliotibial band or gluteus maximus impinging on the greater trochanter
  • Internal or medial ­ caused by iliopsoas snapping over the iliopectineal ligament or femoral head
  • Intra-articular ­ secondary to a loose body

Complication rate

A recent review of 1,054 cases of hip arthroscopy (Clarke 2003) revealed a 4.2 per cent total complication rate. This includes failure to gain adequate access to the hip, and if these cases are removed, then the figure is 1.4 per cent. Complications described are sciatic nerve neuropraxia, femoral nerve neuropraxia, vaginal tear, trochanteric bursitis, portal bleeding, portal haematoma, instrument breakage, arthrotomy and infection.

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