HIP SCOPE INDICATIONS
The hip joint is essentially a ball and socket joint. The socket is known as the acetabulum and is part of the pelvic ring. The pelvis in turn is connected to the spine and via the sacrum. The end of the sacrum is formed by the coccyx. The socket is in fact a horseshoe shaped structure with a small fovea or indent in the middle, to accommodate a ligament (ligamentum teres) which attaches to the end of the ball or femoral head. The ball is attached to a neck which in turn attaches to the shaft of the thigh bone or femur. The ball is covered by a layer of cartilage as is the socket. The hip joint is encapsulated by a dense connective tissue capsule with certain thicker zones that form discrete ligaments. The capsule forms a waterproof compartment for the hip joint and is lined by a membrane called synovium. The synovium produces lubrication fluid for the joint. This fluid is called synovial fluid. When there is inflammation in the joint synovium is irritated and produces more fluid. Attached to the rim of the socket and just inside the capsule is a specialised ligament known as the labrum. I call it “the ring of calamari”, because it looks like this. The labrum forms a seal around the femoral head. It is an essential component of the mechanics of the hip joint because it stabilises the joint, traps a thin layer of fluid between the cartilage surfaces and helps deepen the socket in order to create a larger surface area to accomodate the impact forces through the joint.
PATIENT INFORMATION ON HIP SCOPE (ARTHROSCOPY)(COPYRIGHT)
Keyhole or arthroscopic joint surgery has revolutionized orthopaedic hip joint surgical practice. The most common joints involved in arthroscopic surgery have historically been the knee and shoulder.
In contrast, the development of hip joint arthroscopy has lagged somewhat behind the previously mentioned joints. This is due to the fact that the hip joint is very deep and constrained. As a consequence, in the past many problems related to hip joints have required large open surgical procedures with long recovery times. Fortunately the skills and instrumentation have developed to a point where we are now able to perform hip arthroscopic procedures successfully, resulting in good recovery in a shorter space of time. Hence, we are able to avoid large open surgery for the most part and substitute this for a few small puncture wounds which allow entrance of the arthroscope and specialized instrumentation. Hip joint arthroscopy has also afforded us the chance to manage some hip joint problems which studies have shown may lead to early wear and tear osteoarthritis. These hip joint problems which often occur during sporting and /or traumatic events may now be managed through keyhole surgery and hopefully prevent the early onset of wear and tear arthritis. There are many other indications for hip joint arthroscopy aimed at relieving pain and suffering.
In most cases hip arthroscopy requires an overnight stay in hospital but in some cases this surgery can be done as a day case. The procedure can take anywhere between 1 to 2 hours to perform. Following surgery early active movement of the hip is essential and the services of a physiotherapist are invariably required. (See detailed description at end of page)
INDICATIONS FOR HIP ARTHROSCOPY:
The following are possible reasons for having a hip arthroscopic procedure:
- Diagnostic reasons
- Torn cartilage
- Labral tears
- Femoro-acetabular Impingement
- Torn ligamentum teres
- Psoas tendonitis
- Loose bodies
- Buying time
In a number of cases a patient may present with pain related to the hip joint and following physical examination together with special investigations which include routine x-rays with or without CT scans and/or MRI scans, the surgeon is still unable to make a conclusive diagnosis. Often the patient has undergone a course of physiotherapy but the hip joint pain and/or discomfort is persistent and not relieved by conservative measures. In these cases, hip joint arthroscopy has proved an invaluable tool to aid in diagnosis of a joint problem or in fact the exclusion of the joint as the source of pain. One can not substitute for the ability to be able to look directly at the source of problems in order to come to an answer. More often than not the diagnostic scope can be followed by therapeutic intervention with specialized instruments and so doing avoid large open surgery.
- LABRAL TEAR:
The labrum is a cuff of tissue which surrounds the cup of the hip joint and by so doing deepens the cup and forms a tight seal around the head of the thigh bone which contributes to the ball and socket type hip joint. (It looks like a ring of calamari). This labral seal results in a suction affect which assists in stabilization of the hip joint as well as sealing in a layer of joint fluid which allows near frictionless movement. Labral tears therefore will affect this mechanism and can not only result in hip pain but it is felt in the long term can accelerate wear and tear arthritis. In many cases, labral tears may be addressed by arthroscopic hip joint surgery which will afford an opportunity to debride or smooth out rough torn edges of the labrum and/or perform a suture repair of the labrum depending on the extent of damage. The idea is to restore normal anatomy and thereby treat painful symptoms as well as prevent early onset of wear and tear arthritis. We even go as far as reconstructing the labrum using tissue harvested from elsewhere in the body, so important is this structure.
- TORN LIGAMENTUM TERES:
The ligamentum teres is a vestigial ligamentous structure which connects the head (or ball) to the socket of the hip joint. Its function in the adult is not yet understood completely. This structure can often be torn either subsequent to a traumatic event resulting in a wrenching of the hip joint, or a dislocation. Sporting activities which involve extreme limb positions such as kick-boxing and other martial arts as well as ballet, may often result in a torn ligamentum teres. This can sometimes result in pain and discomfort with associated clicking of the hip as the frayed ends get caught between the joint surfaces. Once again, arthroscopic surgery allows us to deal with this problem without the need for large open surgical procedures and risky dislocation of the ball and socket joint in order to access this ligament.
- LOOSE BODIES:
In patient’s with early wear and tear arthritis or sometimes following trauma, sometimes a piece of cartilage may break off the moving surfaces. This can result in the formation of what is known as loose bodies. These bits of tissue will cause pain and catching symptoms in the hip and can result in further damage to the rest of the joint. Keyhole surgery affords one the ability to remove these loose bits via small incisions with rapid recovery after surgery.
Synovium is the tissue in all our joints that produces the lubrication fluid for joint movement. In, for example, patient’s with rheumatoid arthritis, this synovial membrane often becomes excessively inflamed. It can also be the source of formation of abnormal cartilage deposits in the hip, so called Synonovial Chondromatosis. This results in the typical symptoms of pain and stiffness in affected joints.Arthroscopic surgery affords one the ability to remove almost all the synovium which will ultimately delay damage to the joint and also relieve symptoms related to the inflamed synovium. This surgery was often not done before in the hip joint due to the large surgical exposure required but arthroscopic surgery now allows us the ability to deal with inflamed synovium with minimal damage to the surrounding tissues and this is of great benefit to the patient.
In rare cases there are certain benign tumours which originate from the aforementioned synovial membrane, and results in the formation of many calcified loose bodies within a joint, or simply the synovium proliferates to such an extent that it obstructs joint movement and also causes associated pain. Arthroscopic surgery allows for resection of these tumours without the need for large skin wounds and potential damage to surrounding muscle and tissue. Should the diagnosis of a tumour be in question then a biopsy may be taken arthroscopically and sent to the laboratories for histological (tissue) diagnosis. This would then be a diagnostic arthroscopy which would in all likelihood be followed by therapeutic arthroscopic intervention.
- TORN CARTILAGE:
Torn hip joint cartilage is often secondary to a traumatic event either sporting or otherwise. Torn cartilage also results from cronic FAI (see below). In the past this was treated mainly conservatively and often may result in early wear and tear arthritis. Hip arthroscopy allows surgeons to address the problem area so as to alleviate painful symptoms and optimize the mechanical function of the joint once again.
- FEMOROACETABULAR IMPINGEMENT (FAI):
There are some patient’s that are born with mild abnormalities of the socket orientation and/or they develop problems with the area of growth around the femoral head with a change in shape from the head to the neck. This results in a problem of Femoroacetabular Impingement (FAI) of which there are two types:
- Pincer Impingement
- Cam Impingement
- Mixed Impingement
This can cause damage to the previously mentioned labrum and the socket cartilage and it is felt by many will consequently lead to earlier osteo-(wear and tear) arthritis. There are arthroscopic and open surgical techniques which enable us to recreate the thigh bone head and neck off set and improve on the socket shape which will allow better range of movement and prevent impingement. This is coupled with labral repair or reconstruction. This sort of surgery is fairly technically demanding and involves bony resection, but there is mounting evidence that it is certainly worthwhile in preventing long term arthritis as well as providing early excellent symptomatic relief.
- PSOAS TENDONITIS OR SNAPPING:
The psoas tendon is a large tendon associated with the hip joint which connects 2 large muscles from the spine and pelvis to the lower limb. It is closely applied to the bony pelvis and the hip capsule. In some cases this tendon can become inflamed and can even result in a pronounced click or snapping sensation. If this is the case, the surgery indicated is the release of the tendon which will then heal slightly elongated and thereby relieve tension allowing the pain and clicking sensation to be resolved. This can be done arthroscopically.
Infection in a joint is more typically found in children and in patient’s who are compromised in terms of their immune system. Infection essentially translates to puss within the joint space and this will result in a rapid destruction of cartilage. It is for this reason that surgery is urgently required in order to wash out the joint as soon as the diagnosis is made, to allow healing while preventing further damage to cartilage. Previously this procedure was preformed with a large incision in order to facilitate drainage. Now, it can be done through small incisions and the use of an arthroscope.
- BUYING TIME:
On occasion a patient with early wear and tear arthritis may develop mechanical symptoms such as clicking of the hip with associated pain and restricted range of motion. In this scenario a washout of the joint by means of an arthroscope may be useful in allowing one to continue to function reasonably well with the arthritic hip and thereby buy a few years prior to requiring a total hip replacement or resurfacing. Arthroscopic hip joint surgery allows surgeons to perform this joint debridement with minimal invasion and a quick recovery. The surgery has a low complication rate and does not burn any bridges with respect to future hip replacement surgery. It will hopefully extend the life of the natural hip which remains the gold standard as artificial hips have a limited lifespan and complications, if they occur, are a lot more serious.
It is mainly indicated in those less than 50 years of age. I think this type of surgery should always go together with an adjustment in the type and extent of sporting activities, as impact sports and running will always accelerate wear and tear arthritis in the lower limb.