Listed below is the step by step procedure of hip arthroscopy:
- What is Hip Arthroscopy?
- Why is Hip Arthroscopy Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques Of Hip Arthroscopy
- Post Procedure
- Risks and Complications
What is Hip Arthroscopy?
The hip joint is formed by the articulation of hip bone with that of the femur (thigh bone). It is responsible for bearing maximum weight of the human body at the same time allowing it to perform a range of motions. In some cases, to keep the hip joint working at its optimum capacity, a hip arthroscopy is performed. Small incisions are made in the skin overlying the hip joint. Through these incisions, a device known as arthroscope is passed which contains a small camera on its head. With visuals from the camera, the joint space can be evaluated for any problem and be corrected accordingly. It is a minimally invasive technique and has a good success rate.
Why is Hip Arthroscopy Required?
This is a small representation of what may be the reason you need a hip arthroscopy:
- Femoral acetabular impingement (FAI): There may be an overgrowth of either the thigh bone or the hip bone which causes improper contact at the hip joint. This could impinge on the structures of joint and as a result cause pain and limited movement.FAI is of two types: Cam lesion (abnormal thigh bone) and pincer lesion (abnormal socket/hip bone).
- Labral tears: Labrum is the protective covering of the socket part of the joint. It may get damaged due to trauma, friction etc
- Bone cysts: Commonly found in the hip bone (acetabulum part).
- Tearing of ligamentum teres: The ligamentum teres connects the femur with the acetabulum. It contains a rich supply of nerve fibres and provides blood supply to the femoral head. Sudden trauma, twisting or bending movements can damage this ligament.
- Synovitis: Inflammation of the synovial fluid (shock absorber) in the joint.
- Hip infections: For treatment of hip infections
- Trochanteric bursitis: Inflammation of the bursa (fluid-filled) space near the joint
- Early Arthritis: where there are chances of stabilising the joints.
- Psoas tendinopathy: The psoas tendon helps in the flexion of hip joint. But if the tendinopathy cannot be treated with conventional methods, arthroscopy can be used to perform psoas tenotomy.
- Biopsy: To perform biopsy
Your doctor would discuss the surgical plan with you. You can ask any doubts concerning the surgery, recovery and all the preparations that are needed to be done.Things you should let your doctor know:
- Discuss details of your medical history, whether you are suffering from a heart condition, liver disease, kidney disorders, etc. Do tell if you have undergone any surgery previously.
- If you are allergic to any particular drug or material.
- Details of any current medications such as anti hypertensives, blood thinners, etc.
- If you are pregnant
- If you are suffering from any bleeding disorders
- Whether you consume alcohol or smoke regularly. If you are a smoker, you would need to stop smoking at least two-three weeks before surgery. Smoking compromises blood flow to your organs and delays healing.
- You would need to start exercising. Pre-surgical exercises will help you gain upper body strength in order to bear your own body weight as well as that of crutches after the surgery.
- If on blood-thinners, they need to be stopped 10 days prior to surgery, but take the opinion of your doctor first.
- Dental treatments such as root canals, extractions or any minor elective procedures should be done before the surgery, because you won't be able to get them done for quite some time after the surgery.
- Anti-inflammatory medicines (NSAIDs) need to be stopped at least 7 days before surgery.
- Blood tests: Complete blood count (CBC), hemoglobin (Hb), blood pressure (BP), blood sugar, blood urea, etc.
- Urinalysis: Calculation of specific gravity, presence of proteins, sugar, pus cells or blood. Examination of color consistency may be carried out.
- Imaging tests: X-ray of the hip region to study hard structures. An MRI scan helps to visualise soft tissue structures.
- Electrocardiogram: Heart function is studied by recording electrical activity of heart.
- Renal function tests: To evaluate kidney function.
- Liver function tests: To check for liver disease, because most of the drugs are metabolized in the liver.
Day Before Surgery:
- Do let your doctor know if you are suffering from any fever, chills or infection, as the surgery cannot be performed in such a state. You can reschedule early this way.
- Pack all your essential things you would take to the surgical center. Take lose clothing, your essential medicines, anything to read etc.
- Take care to arrange for conveyance to and from the surgical center.Take care to arrange for conveyance to and from the surgical center.
You are required not to consume any food or drink 8-12 hours before surgery. This helps in easier administration of anesthesia.
- You can wear lose and comfortable clothing so that the bandages are easily accommodated later on. Leave your jewellery and valuables at your home. Nails should be free of any nail polish.
- Bring someone along who will stay with you through the entire procedure.
- If you need to take of your essential medications on that day too, then take them with a small sip of water, not too much.
- You can brush your teeth, but spit the water out.
- The nursing staff will again do a pre-surgical check-up and take your blood samples. Your blood pressure will be measured too. Antibiotics may be injected at this time to prevent any risk of infection later.
- Your doctors will again go through the explanation of surgical process for you. Feel free to ask them queries.
- Finally, you will need to sign the consent form. It outlines the treatment procedure, risks and complications. If you feel you are ready for the surgery, sign it and hand it over to the hospital staff.
- Next you will be draped in a surgical gown and taken to the operation theatre.
The type of anesthesia used in hip arthroscopy is determined by how your body works, what the surgeon would prefer and how much does the procedure demands. Your anesthesiologist will go through the entire discussion about anesthesia with you and clarify doubts if you have them. This procedure can be performed both under general as well as neuraxial (spinal/regional) anesthesia. General anesthesia would be given to you either by inhalation of gases or by an intravenous line. This way you will be asleep throughout the procedure.
If you are going for regional anesthesia, femoral block, lumbar plexus block and/or fascia iliaca block is given to numb the the joint region. Sedatives (drugs that put you to sleep)are given to you in a controlled dose to relax you and put you to sleep.
Methods/Techniques Of Hip Arthroscopy
- The operation theater is a completely disinfected place with all the instruments sterelised.
- You would be made to lie on the operation table on the back (supine position) or on the side (lateral decubitus). A traction table or different devices are used to apply traction to your affected leg. It is done to separate the 'ball' from the 'socket' to allow for sufficient access in the joint space. A few millimeters of traction is achieved this way.
- Adequate padding would be placed on the operating table to support your body throughout the surgery and avoid any undue pressure on the pudendal, femoral, obturator or peroneal nerves.
- After this, the area is painted with disinfectant and the surgery starts.
- The important anatomic landmarks are marked on the skin with an indelible marker.
- Now a fine needle will be inserted to break the suction seal of hip joint to allow for further separation (hence more access).
- Arthroscopic fluid is inserted which makes it easier to see the joint space clearly and make space for insertion for instruments.
- The needle which was placed first is now removed and small points of entry (portals) are made on the skin using a new hollow needle, but in a different position.
- A thin guide wire is passed through the hollow needle into the joint with help of X-ray guidance and the hollow needle is removed.
- The area around the guide wire is cut so that a cannula can be placed over it. After it is placed properly, the guide wire is removed. This is the first portal of entry through which further instruments can be inserted.
- Once the arthroscope is inserted, visual feed from the camera can now allow the surgeon to judge and create more portals of entry. At most, 4 portals can be made.
- Thus, one portal holds the arthroscope and others carry the surgical instruments (radiofrequency probe, hook probes, anchors etc.). Now any type of repair required is possible.
- After surgery is complete, traction is slowly released and this brings the ball and socket back to its original position, and position of the arthroscope is shifted.
A few repairs that are carried out using arthroscopy:
- Hip impingement syndrome (FAI): It is the impingement of articulating surfaces of the hip joint due to abnormal contact of the thigh bone with the hip bone. Cam-type (problem in femur) FAI and pincer-type FAI (problem in hip joint) are two variants. Technique involves debridement and repair of any injuries to cartilage and labrum, or recontouring head of femur or the overextended hip bone (acetabulum).
- Labral tears: Labrum is a covering in the acetabulum which stabilises the hip joint and acts as a shock absorber. Excessive compression forces, or trauma, may damage the labrum and cause pain in the lower back, buttock, knees. Repair is possible by debriding or by stablising it against the hip bone using anchors. Nowadays, grafts are gaining popularity to repair the damaged labrum.
- Bone cysts: The bone cysts are removed and bone graft is filled in place.
- Synovitis: The inflammation of synovial fluid is removed via synovectomy.
- Articular cartilage damage: Early stages of arthritis are possible to be treated using this method. 'Microfractures' are made to stimulate growth of new cartilage.
Though minimally invasive, hip arthroscopy takes more time than a hip replacement surgery. 2 hours is the average time taken.
Once the surgery is done, you will be shifted to a Post-Anesthesia Care Unit (PACU), where the nursing staff will take good care of you. Once you wake up, your doctor will give you all the necessary instructions and precautions to be followed at home. Make sure you have a near one along with you to understand these home care instructions.
Strong pain medications (narcotics) will be given to you. Take them exactly as per the instructions given by the doctor. Drink lots of fluids and consume more fibres to soften their effects. If you were on any pain medication such as paracetamol, start taking them only after permission. In some cases, when pain medication cannot be taken orally, regional anesthesia can be given such as nerve blocks. But nerve blocks can only dull the sensation of pain and not give any support from the hip joint or lower body.
The next day after your surgery, dressing will be removed and replaced with a fresh one. Your stitches will be removed 10 days after surgery. Try to keep incision area dry and not apply anything over it.
You can start bathing 2-3 days after surgery, but avoid the contact of water with your incisions. Sponge baths are best.
Use ice packs for at least 4 times for the first few days. If you have more pain, increase the number of times you use them. Ice packs control the extent of inflammation.
With respect to general day to day activities, avoid bending too much (not more than 90 degrees) and don't try to pick up things if they have fallen down. Try lying on your stomach for at least 2-4 hours daily. While choosing a chair, opt for those which have armrests so that you can push them and then get up. But don't make a habit of getting too comfortable in the chair! Always ensure that the path in front of you is clear and avoid any obstructions in the way. If you see water on the bathroom floor, see if you can go to a dry one. Use a CPM (Continuous Passive Machine) at home for the first few days.
Your physiotherapy should start as soon as possible, mostly within three days of the surgery. Your physiotherapist will discuss the entire exercise regime with you. It is important that you follow the exercises religiously, as they will help decrease the intensity of pain. At least 1-1.5 months of rigorous therapy is essential to restore hip function properly.
You can start learning how to balance your weight on crutches and using additional support to walk properly. Your physiotherapist will particularly emphasise on learning to climb and descend from the stairs using crutches. Even when getting down from your bed, you should first put the operated leg on the unoperated one and then slowly turn to put your feet on the ground. This relieves the hip muscles.
Exercises should be done at least 3-4 times daily. Ankle rotations, glute sets, heel digs (hamstring isometrics) and quadricep isometrics are helpful.
Aquatic therapy is an advanced, but more relaxed way of exercising. The water does not allow much stress to be conveyed to the hip joint and routines can be done here under the supervision of a trainer.
Approximately 5-6 months of time is needed for full pain free functional stability of the hip-joint.
These are the general guidelines for follow-up schedule after hip arthroscopy:
- The next day immediately after surgery
- A week to 10 days after surgery. Post-op X-rays will be taken and recovery would be discussed.
- 2 months after surgery
- 4-5 months after surgery to check the impact on your day to day activities
- 6 months-1year later, if you are a regular participant in sports
Risks And Complications
Hip arthroscopy has steadily grown in popularity over the years. With new techniques, complications have a very low rate of occurrence (6.4%). But chances of major damage still lingers. For your convenience, we can divide the complications into two categories:
- General complications
- Complications with respect to hip arthroscopy specifically
- Vascular: There is a possibility of formation of blood clots, leading to more chances of deep vein thrombosis.
- Anesthetic: Nausea, vomiting, headache, dizziness, respiratory depression, abnormal rhythm of the heart (arrhythmia), even death.
- Urinary: Inability to pass urine properly.
- Cardiac: Chances of heart attack.
Complications With Respect to Hip Arthroscopy
- Damage to nerves: It can be temporary or permanent. In temporary injuries (neuropraxia), the function will return after some time, but permanent injuries (neurotmesis), the nerve function will never return. Femoral, sciatic, pudendal, obturator and lateral cutaneous nerve of the the thigh are most commonly affected nerves.
- Infections: The articular cartilage of the joint is susceptible to infections. However, infections are a rare occurrence with hip arthroscopy and giving intravenous antibiotics before the surgery solves most of the issues. Antibiotic dose can be prolonged for some more days after arthroscopy.
- Skin (cutaneous) issues: There can be keloid formation (a scar extending beyond its normal boundaries), damage to genitalia, pressure sores, small tears in the vagina or delayed healing.
- Delayed wound healing
- The irrigation fluid used during arthroscopy may escape into surrounding soft tissues and cause pain later on.
- Brushing: Brushing of the articular surface of the joint. The joint may get dislocated in some cases.
- Vascular complications: Bleeding may occur during the surgery as a few major arteries are located in the region (such as femoral artery). It is normal to have some post operative fluid oozing out. But bleeding from the sites of incision is not alright and should be brought to the notice of the doctor as soon as possible.
- Trochanteric bursitis: It is the inflammation of the fluid-filled sac near the hip joint. It could be an inflammation by itself or a result of blood accumulation in the joint during surgery.
- How long would I be using crutches post hip arthroscopy?
A. The time spent on crutches varies depending on the procedure for which arthroscopy is done. It may be 2-4 weeks for impingement lesion repairs to 6 weeks post microfracture procedures.
- When can I drive after hip arthroscopy?
A. If you have an automatic car, you can start driving after 2 days. But if you have a car with manual gears, you would like to wait for 2-3 weeks.
- How long will I be off work?
A. If you have a very low intensity, desk-job type of work, you can resume working within 2 weeks. But in cases where a lot of physical work is required, 2-3 months are needed to recover properly to be able to work efficiently.
- How much could the pain subside without surgery?
A. If you are a candidate for surgery and you try reducing your pain by limiting strenuous activity, it may help in the short run. But eventually, surgery will be the permanent option.
- Is it possible that my pain would worsen after surgery?
A. You will feel some pain after surgery for a few weeks until rehabilitation is complete. It is rare for pain to continue after that. If you do feel something is wrong, contact your doctor at the earliest.
Hip arthroscopy is a procedure that offers many benefits. It is usually done on an outpatient basis (provided patient is healthy) and produces less scarring. The best part is that it has faster recovery time with less chances of risks and complications. The information provided here is not exhaustive but can serve as a small map to help you with the process.
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