In the past, if you wanted to gain surgical access into a hip joint, you had to undergo a major procedure. This involved a large incision, the cutting through of the surrounding hip musculature and supportive ligaments, so that the surgeon could dislocate the hip – literally popping the head of the femur out of the socket. Whilst this gains great visual access, it is also very destructive to tissue, and the procedure permanently damages the ligamentum teres – a ligament we increasingly recognise to be involved in hip positional sensing and stability. Thankfully, techniques have evolved which means that the skilled surgeon can access the hip arthroscopically, i.e. via a key hole procedure, which does not require the hip to be dislocated. Under a general anaesthetic, an ‘arthroscope’ or tiny camera, is passed into the hip, so that the surgeon can see inside hip joint, and use instruments to carry out repair work to structures such as the hip labrum.
Hip arthroscopy is typically carried out as a day case procedure, under a general anaesthetic. The hip is held together by strong muscles and ligaments, but also by a slight negative pressure, which in effect creates a vacuum within the joint. To get into the hip, this vacuum needs to be released. This is done by very gently pulling or distracting the hip, with the gentle stretch being applied via the foot, which is placed in a sort of ski-boot. With this very gentle stretch applied, the surgeon can then place a needle into the hip (under x-ray guidance), which allows air to rush in, filling the vacuum. The joint literally relaxes a bit, which gives the surgeon a little more space to then be able to pass a probe into the hip, through an incision measuring about a centimetre in length. Three or four of these access points via incisions in the side (lateral area) of the hip are made, so that the surgeon can ‘see’ via camera into the hip, and instruments can be passed in and out of the hip to perform the surgery.
Every hip requiring arthroscopy is a little different. Typically, a patient may have damage to or separation of the labrum (which is the ring of gristle surrounding the entrance to the hip) from the bony socket (acetabulum). Depending on the type of tear, the labrum may be either trimmed (debrided) or repaired with sutures. Various techniques are available for labral repair, mainly using ‘anchors’, which may be used to tie down the labrum to the underlying acetabulum, allowing it to heal in a correct position.
Some patients additionally have damage to the articular cartilage (which lines the joint surface), in the part of the socket adjacent to the labrum. Whilst the human body cannot replace this cartilage with like-for-like, the body can be triggered into developing a second-best form of scar cartilage, through a technique called micro fracture – all of which can be done through the arthroscope.
If a patient has a ‘CAM’ type of impingement lesion within the hip, this has to be dealt with to prevent the damaging effects of it continuing to knock into the labrum. The surgeon can reshape this ‘bump’ at the head-neck junction of the upper femur, using a high-speed motorised burr – a bit like the tool a dentist would use to burr the edge of a tooth.
Some patients have a ‘pincer’ form of FAI, as if the socket has a very narrow or pinching entrance. This means that repeated contact between the femoral neck and the edge of the ‘pinching’ acetabulum may lead to damage to the labrum and adjacent articular cartilage. The goal of the arthroscopic treatment for pincer impingement is to reduce the acetabular ‘over coverage’ of the hip. Methods to reduce this over coverage of the ball by the socket include labral detachment, acetabular rim recession (trimming back) using burrs and the reattachment of the labrum with anchors at the end of the procedure.
A hip arthroscopy procedure takes around an hour and half, and it is technically demanding work, in a very narrow space. The scopes are withdrawn from the hip, and the incisions or ‘portals’ are then sutured closed. Once the patient is awake, they then return to the day care ward, and seen by a physiotherapist. The majority of patients will go home the same day of the procedure. Most patients require the use of crutches for a few days, but then they can come off them, when they are able to walk comfortably unaided.
Hip arthroscopy rehabilitation takes a surprisingly long time – and at least 16 weeks of rehab is needed. At Sport Hip, we are very experienced in guiding you through this process, and we work closely with all those involved in your post-operative care.