Hip Arthroscopy Patient Handout - What is the anatomy and function of the hip? The hip joint is the connection of the “ball” (head of the femur bone) with the “socket” (acetabulum of the pelvis). It supports the weight of the body in static and dynamic postures, and allows for a wide range of movements. The hip is comprised of several bones, as well as three key ligaments which reinforce the joint: the iliofemoral ligament, the pubofemoral ligament and the ischiofemoral ligament. The hip joint also includes the labrum which is a ring of cartilage that surrounds the “socket” and holds the “ball” in place, making the joint harder to dislocate.

Fig 1 Diagram of Right Hip Fig 2 X-Ray of the Pelvis - What is a hip injury? The hip joint is susceptible to many musculoskeletal injuries which include arthritis, dislocation, impingement, labral tears and damage to the surrounding muscles, tendons and ligaments.

Symptoms of a hip injury may include:

 Pain while walking or pivoting

 Pain at night

 Decreased mobility or flexibility

 Catching, popping or grinding of the joint Injuries to the hip may result from acute trauma, such as a fall or motor vehicle accident, or chronic wear and tear. Diagnosis will include a comprehensive physical examination to determine range of motion, stability and pain, as well as an X-ray, MR arthrogram to determine the nature of the injury and an intra-articular injection.

- What is hip impingement? Hip impingement or femoroacetabular impingement (FAI), encompasses conditions of the hip in which the shape of your hip bones do not permit normal movement of the hip and may cause pain. Abnormal bone shape can be on the femur (CAM impingement), on the rim of the acetabulum (Pincer impingement), or both. The rubbing of the bones in an abnormal fashion can cause pain and lead to damage of other structures in the hip including the cartilage and acetabular labrum.

Fig 3 Diagram of the Right Hip Demonstrating Fig 4 X-Ray of the Right Hip Demonstrating Pincer CAM and Pincer Impingement Impingement

Fig 5 X-Ray of the Right Hip with CAM impingement Fig 6 Joint degeneration as a result of FAI

A type of non-bony hip impingement exists called iliopsoas impingement. The iliopsoas is the main muscle that flexes the hip. This muscle-tendon complex crosses outside the hip joint capsule and excessive friction or pressure of this tendon on the capsule can cause symptoms in your hip. Individuals with iliopsoas impingement may experience an internal snapping sensation in the groin, a popping sensation and/ or simply groin pain. The pain from this condition is often a result of an inflamed capsule, inflammation of the labrum, and/ or labral tears caused by the iliopsoas impingement. - What is a labral tear? The fibrous cartilage lining of the acetabulum (socket), the labrum, may be torn through various mechanisms including impingement and trauma. Many individuals have labral tears and labral tears may or may not cause an individual to experience symptoms in their groin and hip. The injection you have or may get into your hip helps determine if the labral tear is contributing to your hip pain. Some symptoms of labral tears are locking, catching, and/ or pain in the groin.

Fig 7 MR Arthrogram Slices Demonstrating Labral Tears

- What is a loose body? A loose body is one or multiple pieces of tissue or bone that have fragmented from their normal position in the joint and are no longer attached properly. These fragments become free to move about the joint and may damage normal tissue and cause pain and/or a catching sensation. These fragments can result from trauma, such as a fall, motor vehicle accident, or sport injury. - What is a hip cartilage injury? The surface of the head of the femur and corresponding surface on the acetabulum are lined by a surface known as articular cartilage. This surface allows smooth motion within the hip joint and can be found in various other joints including the shoulder, knee, and ankle. The concern about articular cartilage injury lies in the lack of potential for this type of cartilage to regenerate and heal when significantly damaged. Patients that sustain trauma to the hip joint and/ or have chronic impingement may damage this cartilage. Usually, the cartilage begins degeneration by undergoing softening. When associated with impingement, the second stage of cartilage injury usually involves the detachment of the cartilage from the underlying bone. This can be thought of as a bubble of cartilage. The next stage of cartilage injury is generally detachment of the bubble to the point where it becomes a cartilage flap. This cartilage flap will not heal back to the bone on its own. Untreated flaps encourage further cartilage degeneration and the progression of osteoarthritis within the hip joint.

Fig 8 Diagram of Right Hip displaying the Fig 9 Arthroscopic View of an Acetabular Cartilage Flap articular cartilage in white

- What non-operative treatments are available for my hip injury?

Nonsurgical treatments for a hip injury typically include a modification of activities, physical therapy exercises to stretch and strengthen the joint and/ or non-steroidal anti-inflammatory medications to relieve pain. Non- surgical means are often prescribed before any surgical options are recommended.

- What should I expect during my hip evaluation?

When you arrive to the office for your hip evaluation you will be required to report to the reception desk and asked to fill out necessary paperwork. Following completion of these administrative tasks your visit will likely proceed with an initial X-ray evaluation of your hip. X-rays are an orthopaedic surgeon’s stethoscope and will allow Dr. Wright to evaluate your hip alignment, joint space, and bony morphology. Should you have prior x- rays or MRI(s), we ask that you bring them with you on a CD or DVD so that Dr. Wright can evaluate these pictures of your hip. Following your x-rays, you will have a consultation with Dr. Wright. Dr. Wright will speak to you about the history of your hip problem, aspects of your life affected by your hip, inquire about associated conditions, review your available imaging studies, and examine your hip. Your hip evaluation will include various examination tests including observation, palpation, standing on one leg, manual strength tests, and numerous range-of-motion tests which may or may not illicit symptoms in your hip. Dr. Wright will then develop a treatment plan based on your history, past tests, and clinical examination.

If physical therapy has not been prescribed in the past, Dr. Wright may recommend a course of therapy in an attempt to relieve your symptoms non-operatively. Also, additional imaging studies including a magnetic resonance arthrogram (MRA) and/ or a diagnostic hip injection may be prescribed. If a diagnostic injection is prescribed, you will be asked to remember the percent relief of your symptoms with the injection and the time frame associated. This information will be discussed at your follow-up visit.

- What is hip arthroscopy?

Arthroscopic hip surgery involves making 2 or 3 small incisions around your hip and looking inside the joint with a camera that is around the same diameter as a pencil. While the camera is inserted in one small incision, the other incision(s) will be used to place various instruments in the joint in order to treat the cause of your hip discomfort. Arthroscopic hip surgery is a treatment option for various hip conditions including labral tears, impingement, cartilage injuries, and removal of loose bodies. Arthroscopic surgery will be recommended for injuries that do not respond to non-surgical methods and involve weakness, loss of function, and/ or pain. The advantage of arthroscopy to traditional open surgery is that the joint does not need to be completely opened up, and no muscles are cut or displaced. This reduces the recovery time and may increase the success rate due to reduced trauma to the joint.

- What are the reasons to have arthroscopic hip surgery?

Arthroscopic hip surgery may be the best option to achieve the following should non-operative management prove to be inadequate:

 Relieve pain

 Restore motion

 Improve quality of life

 Return to sports

 Restore the ability to perform activities of daily living

 Treat the underlying cause of your hip symptoms including impingement, labral tears, loose bodies, and/ or articular cartilage injuries.

 Delay osteoarthritis

 Delay the need for a total joint replacement - Arthroscopic Treatment of Femoralacetabular Impingement (FAI)

Arthroscopic treatment of FAI involves shaving away the extra bone, an osteoplasty, of your femoral neck (CAM impingement) and/ or on your acetabulum (Pincer impingement) to allow the bones of your hip to move without rubbing together. This is performed with small arthroscopic instruments called burrs. In order to ensure all of the bony impingement is removed, Dr. Wright will intraoperatively observe the internal motion of your hip with the arthroscope.

Fig 10 Using an Arthroscope Burr to Perform a Femoral Arthroplasty

- Arthroscopic Treatment of Labral Tears

Arthroscopic treatment of a labral tear is dictated by the extent of injury sustained to this structure. When the labrum becomes separated from the acetabulum, it can often be repaired by using small bone anchors to suture it back in place. This helps to restore more normal anatomy of the labrum. On the other hand, chronic hip impingement or trauma often damages the labrum to a point in which it cannot be repaired. When this is the case small arthoscopic instruments are utilized to excise or trim away the damaged portion in order to return the labrum to a more stable state. This is known as a labral debridement.

- Arthroscopic Treatment of Iliopsoas Impingement

Iliopsoas Impingement can be treated arthroscopically through a procedure called an iliopsoas lengthening, or tenotomy. During surgery, Dr. Wright will first identify arthroscopic signs of iliopsoas impingement including an inflamed capsule, inflamed labrum, and/ or labral tears adjacent to the crossing of the iliopsoas tendon. If one or more of these signs is present than Dr. Wright may proceed to lengthening the iliopsoas tendon. This involves making a small cut in the tendinous portion of the muscle at the level of the hip joint which takes the pressure off of the capsule and labrum. This allows the muscle to heal in a slightly lengthened position. This procedure is very often combined with appropriate arthroscopic treatment of associated labral injuries.

- Arthroscopic Treatment of Articular Cartilage Injuries

The extent of cartilage damage is not always completely visualized by pre-operative magnetic resonance imaging. Therefore, cartilage injuries need to be explored during the operation and Dr. Wright will determine the best treatment option intraoperatively. The first stage of cartilage injury, softening, does not require operative treatment although the underlying cause of this change, such as impingement, should be corrected to prevent progression of the injury. The best methods of preventing progression of the second stage, bubbling, are under investigation and our team is currently exploring ways to repair this detachment including gluing the bubble back to the bone. As with cartilage bubbles, many options are being explored to treat cartilage flaps. One of the current treatment methods is to excise a cartilage flap and stimulate the underlying bone to heal and produce cartilage through a method called microfracture. The cartilage that grows over this bone is a fibrous cartilage which is not the same as the original articular cartilage. While fibrous cartilage coverage of these areas is significantly better than leaving the bone exposed, it is not nearly as effective as the original articular cartilage. Other potential treatment methods for this type of injury include using a type of glue to reattach the cartilage flap or implanting cartilage cells from a cadaver (allograft). These methods are under continuous investigation and initial results have been favorable.

- Arthroscopic Treatment of Loose Bodies

Hip arthroscopy has emerged as a highly successful, less-invasive means of removing loose bodies from the joint. During the surgery, loose bodies will be sought out with the arthroscope. When loose bodies are found various arthroscopic instruments including graspers, shavers, and radiofrequency devices may be utilized to excise these from the joint. Once excised, your joint will be inspected with the arthroscope to confirm removal of all loose bodies. Your operation may involve any combination of the above procedures depending on the injury present in your hip.

- Rehabilitation after Hip Arthroscopy

Rehabilitation after hip arthroscopy is just as important as the procedure itself. Without proper rehabilitation, pain in the hip may continue and you may develop significant weakness and/ or stiffness which will prevent you from returning to sporting activities and even normal daily activities.