Arthroscopic hip surgery is a minimally invasive method of looking into a hip joint to diagnose and treat certain hip disorders. The most common problem I treat is a so-called labrum tear. The labrum is a ring of cartilage around the hip socket that acts to stabilize and seal the ball and socket joint. When there is a labral tear, there are a number of problems that occur. Some people have dull or sharp pain in the groin with activities. Sometimes people will feel an ache that goes through the groin to the back of the hip like a stabbing sensation going from front to back. I also hear people who describe a popping/catching of the joint with certain positions of the leg or activities.
I will sometimes inject the hip joint under ultrasound guidance in the office with local anesthetic to help confirm that the hip socket is where the pain is coming from. You want to make sure that a separate issue, such as a pinched nerve in the back, is not the main issue. Pinched nerves are notorious for acting like hip problems.
If there has not been an MRI performed, I usually order one to get images of the labrum. The MRI shows the labrum more accurately if there is fluid injected into the hip that helps to reveal the labral tear.
The gold standard for diagnosing joint disorders remains a surgeon’s eyes looking through a camera inside the joint. MRI has become more accurate over the past few years, but it is not perfect. It turns out that many patients who have cartilage tears in the hip have ‘normal’ MRI scans. Therefore, some people are candidates for hip arthroscopy if the pain issues and physical examination are typical of a labral tear.
So when it is appropriate to consider arthroscopy? I will typically prescribe at least one trial of physical therapy. Some people will improve a great deal with therapy and may function well. I can also inject the hip with steroid to give longer lasting pain relief. Studies have shown that steroid can cause long term problems with cartilage degeneration in the hip, so I am hesitant to inject steroid into the hip when there is no pre-existing arthritis. Platelet rich plasma (PRP) is an injectable that may help to facilitate healing of the tear. There are studies currently exploring how well that can work. Since PRP is using your own blood, there is no risk of damaging the hip. You can refer to my PRP blog entry to learn more about that procedure.
If conservative treatments have failed to improve quality of life, then a person can consider arthroscopy. The long term concern with a torn labrum is that the risk of developing arthritis in later years is increased. The goal is to restore the normal anatomy and stability of the joint to minimize damaging shear forces that lead to arthritis.
The surgery itself can take 1-2 hours depending on how much work has to be done, and the difficulty of a particular person’s anatomy. This is done under a general anesthetic in an outpatient setting. During surgery, I typically use 2 small incisions (each about the width of a fingernail). Using live x-ray, I find specific locations in the hip joint and insert the camera. At that point the hip joint is visualized and labral (or other cartilage) problems can be identified. I can then address the labrum with a repair or debridement. Debridement is when the tissue is cleaned out because it is macerated and not repairable.
A repair is accomplished with suture anchors. These are devices that lock stitches into the socket bone. The stitches can be passed into the detached labral tissue and then secured to the bone to help it heal together. Sometimes there is a bump of bone on the ball called a cam lesion. The cam lesion may play a role in causing the tear in the first place. I will therefore shave the bump of bone down to a smooth surface in order to stop the ‘impingement’ of the cam lesion on the repaired labrum.
Patients go home 1-2 hours after surgery. For the first few weeks, crutches are used to help share the weight while walking (so-called ‘touch down weight bearing’). Many people see improvement in pain within the first few weeks, but the process of healing and rehabilitation can take up to one year in total. I will keep athletes out of their sport for at least 4 months (depending on the impact level). Sport specific training may start by 2-3 months after surgery if inflammation and pain are well-controlled.