Hip Arthroscopy: History and Current indications

Paul E. Beaulé, M.D., FRCSC
Associate Professor
Head of Adult Reconstruction, The Ottawa Hospital
University of Ottawa
Ottawa, ON

History and Background
Over the last few years, several authors have provided reviews on the history and clinical indications for hip arthroscopy1-3. It is interesting to note that some of the early reports on hip arthroscopy were in children, where it mainly served a diagnostic role as well as for debridement of articular damage4,5. Byrd attributes the first record of hip arthroscopy to Burman in 19313. Burman's description was based on a cadaveric study of arthroscopic techniques applied to various joints of the human body. In regards to the hip, he felt that "visualization of the hip joint is limited to the intracapsular part of the joint. It is manifestly impossible to insert a needle between the head of the femur and the acetabulum."

 

These comments obviously limited the evolution of hip arthroscopy for a significant period of time with most of the experience being acquired in the peripheral compartment6. This also led some of the early developers of hip arthroscopy to adopt the lateral position in order to achieve proper distraction of the hip joint1,2. In their classic description of the lateral position for hip arthroscopy, Glick and associates2 justified the lateral position because of the inability to remove loose bodies in the posteroinferior aspect of the hip joint with the patient in the supine position2. Having said that, some of the early reports were on hip arthroscopy done in the supine position with the use of an orthopaedic fracture table4,5. Thomas Byrd has since perfected the supine approach for performing hip arthroscopy which provides the added advantage of facilitating an anterior hip arthrotomy to address pathologies within the peripheral compartment7,8. Other initial major contributors to hip arthroscopy are Joseph McCarthy and Richard Villar who both expanded our understanding of intra-articular hip disease as well as refined the indications for hip arthroscopy through their publications9-12.

 

Indications
Hip arthroscopy. like other arthroscopic techniques. was initially used as a diagnostic tool and for removal of loose bodies. As surgeons started to investigate more intra-articular sources of hip pain, pathologies of the labrum were often identified, leading to a natural evolution for treating labral lesions by hip arthroscopy10,13,14. With the advent of more advanced imaging technique such as MR arthrography15-17 as well as multiplanar imaging, the role of hip arthroscopy as a diagnostic tool is minimal; whereas its usage as an effective technique in treating pre-arthritic conditions has become significant. This is evident in the growing body of literature on the use of hip arthroscopy, as well as recent industry reports which project an average annual growth rate of 15% through 2013; with 33 000 hip arthroscopies being performed in the US alone in 200818.

As with any relatively new orthopaedic technique, making an accurate diagnosis will remain a key factor in maximizing the clinical outcome in the management of patients with pre-arthritic hip pain. In a recent paper, Burnett and associates19 documented that patients visited on average 3.3 health care providers prior to being correctly diagnosed with a labral tear and waited an average of 21 months for the diagnosis. More importantly, 33% of patients (22 of 66 patients) received an alternate diagnosis prior to being diagnosed with a labral tear. In addition, it is clear that the majority of patients presenting with a labral tear have underlying bony abnormality such as dysplasia or femoroacetabular impingement (FAI)20-22 (Table 1). Not dealing with the underlying bony abnormality and treating the labral lesions in isolation carries a high risk of reoperation23. Some bony abnormalities associated with FAI can also be addressed at the time of the hip arthroscopy. This is the case for the cam lesion where a femoral chondro-osteoplasty can be effectively done either purely arthroscopically24, or by means of mini anterior hip arthrotomy8. Conversely, addressing acetabular over coverage (retroversion, coxa profunda) associated with pincer deformity should be approached with greater caution as postoperative hip instability after acetabular rim trimming has been reported25,26. Further research is required to determine how to address combined deformities in FAI. These are present in about 40%27,28 of the cases; with correction of cam deformities providing most predictable outcome.

 

Current Indications

 

  • Central Compartment, done with in hip traction:
    • Labral Tears (debridement and/or refixation)
    • Acetabular Chondral Flaps
    • Loose Body/Pigmented Villonodular Synovitis
    • Inflammation of the Ligamentum Teres
  • Peripheral Compartment, no traction with hip slightly flexed:
    • Osteochondroplasty of femoral head/neck junction
    • Release of Iliopsoas Tendon
    • Synovectomy
  • Extra Articular:
    • Release of Snapping Iliotibial Band
    • Repair Gluteus Medius avulsion

Overview
Hip arthroscopy is a rapidly evolving surgical field in orthopaedic surgery with a definite role in the treatment of pre-arthritic hip pain. However, research is still required to better delineate the appropriate indications of this surgical procedure with regard to pain relief for patients suffering from pre-arthritic pain, and delay or prevention of the onset of hip arthritis. Finally, I would strongly recommend that surgeons who are interested in hip arthroscopy visit surgeons with a vast experience with this procedure and be sure to use arthroscopy instruments specifically designed for the hip.

Table 1: Key Radiographic Features of Dysplasia and Femoroacetabular Impingement

 

Dysplasia

Femoroacetabular Impingement
Pincer Type

Femoroacetabular Impingement
Cam Type

Anterior-Posterior Pelvis Radiographs

Centre Edge (CE) Angle 10

Cross Over and/or posterior wall sign
Ischial Sign
Coxa Profunda

Pistol Grip Deformity

Lateral Radiograph

---------------------

---------------------

Alpha Angle > 50 degrees 
Offset Ratio < 0.15

False Profile View

Anterior Centre Edge Angle (ACE) < 25

Narrowing of the posterior articular surface

 

References

  1. Hawkins R.B. Arthroscopy of the hip. Clin Orthop 1989;249(249):44-7.
  2. Glick J.M. Hip arthroscopy using the lateral approach. Instr Course Lect 1988;37:223-31:223-31.
  3. Byrd J.W. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10(3):275-80.
  4. Suzuki S., Awaya G., Okada Y., Maekawa M., Ikeda T., Tada H. Athroscopic diagnosis of ruptured acetabular labrum. Acta Orthop Scand 1986;57:513-5.
  5. Hogersson S., Brattstrom H., Mogensen B., Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop 1981;1(3):273-8.
  6. Dorfmann H., Boyer T. Arthroscopy of the hip: 12 years of experience. Arthroscopy 1999;15(1):67-72.
  7. Sekiya J.K., Wojtys E.M, Loder R.T., Hensinger R.N. Hip arthroscopy using a limited anterior exposure: an alternative approach for arthroscopic access. Arthroscopy 2000;16(1):16-20.
  8. Laude F., Sariali E., Nogier A. Femoroacetabular impingement treatment using arthroscopy and anterior approach. Clin Orthop Rel Res 2009;467(3):747-52.
  9. Keene G.S., Villar R.N. Arthroscopic anatomy of the hip: an in vivo study. Arthroscopy 10, 392-399. 1994. Ref Type: Journal (Full)
  10. Lage L.A., Patel J.V., Villar R.N. The acetabular labral tear: an arthroscopic classification. Arthroscopy 1996;12(3):269-72.
  11. McCarthy J.C. The role of hip arthroscopy in the diagnosis and treatment of hip disease. Can J Surg 1995;38(Suppl. 1):S13-S17.
  12. McCarthy J.C., Noble P.C., Schuck M.R., Wright J., Lee J. The Watershed Labral Lesion. J Arthroplasty 2001;16(8 (Suppl. 1)):81-7.
  13. Santori N., Villar R.N. Arthroscopic findings in the initial stages of Hip osteoarthritis. Orthopedics 1999;22(4):405-9.
  14. Ikeda T., Awaya G., Suzuki S., Okada Y., Tada H. Torn acetabular labrum in young patients. J Bone Joint Surg 1988;70B(1):13-6.
  15. Czerny C., Hofmann S., Neuhold A., Tschauner C., Engel A., Recht M.P., et al. Lesions of the acetabular labrum: accuracy of MR imaging and MR arthrography in detection and staging. Radiology 1996;200(1):225-30.
  16. Leunig M., Werlen S. Ungersbock A., Ito K., Ganz R. Evaluation of the acetabular labrum by MR Arthrography. J Bone Joint Surg 1997;79B(2):230-4.
  17. Ziegert A.J., Blankenbaker D.G.., DeSmet A.A., Keene J.S., Shinki K., Fine J.P. Comparison of standard hip MR arthrographic imaging planes and sequences for detection of arthroscopically proven labral tear. Am J Roentgenol 2009;192(5):1397-400.
  18. Millennium Research Group. An evolution in keyhole surgery: arthroscopy goes for the hip. IQ Industry Insight , 1-3. 2009. Ref Type: Pamphlet
  19. Burnett S.J., Della Rocca G.J. Prather H., Curry M., Maloney W.J., Clohisy J.C. Clinical Presentation of Patients with Tears of the Acetabular Labrum. J Bone Joint Surg 2006;88(7):327-33.
  20. Peelle M.W., Della Rocca G.J., Maloney W.J., Curry M.C., Clohisy J.C. Acetabular and Femoral radiographic abnormalities associated with labral tears. Clin Orthop 2005;441(441):327-33.
  21. Wenger D.E., Kendall K.R., Miner M., Trousdale R.T. Acetabular labral tears rarely occur in the absence of bony abnormalities. Clin Orthop 2004;426(426):145-50.
  22. Guevara C.J., Pietrobon R., Carothers J.T., Olson SA., Vail T.P. Comprehensive morphologic evaluation of the hip in patients with symptomatic labral tear. Clin Orthop Rel Res 2006;453(453):277-85.
  23. May O., Matar W.Y., Beaule P.E. Treatment of failed arthroscopic acetabular labral debridement by femoral chondro-osteoplasty. A case series of five patients. J Bone Joint Surg 2007;89B(5):595-8.
  24. Byrd J.W., Jones K.S. Arthroscopic femoroplasty in the management of cam-type femoroacetabular impingement. Clin Orthop Relat Res 2009;467(3):739-46.
  25. Ranawat A.S., McClincy M., Sekiya J.K. Anterior dislocation of the hip after arthroscopy in a patient with capsular laxity of the hip. A case report. J Bone Joint Surg 2009;91(1):192-7.
  26. Matsuda D.K. Acute iatrogenic dislocation following hip impingement arthroscopic surgery. Arthroscopy 2009;25(4):400-4.
  27. Allen D.J., Beaule P.E., Ramadan O., Doucette S. Prevalence of associated deformities and hip pain in patients with cam type femoroacetabular impingement. J Bone Joint Surg 2009;91B(5):589-94.
  28. Beck M., Kalhor M., Leunig M., Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. J Bone Joint Surg 2005;87B(7):1012-8.

 

 

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