Application of Hip Arthroscopy

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Application of Hip Arthroscopy

• Nadhaporn Saengpetch, MD.

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Objectives

• To understand the spectrum of disease that is
  compatibly treated with hip arthroscopy
• Have a basic understanding of the relevant
  anatomy , history and examination for hip pain
• To introduce the surgical technique and its
  limitation

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Once upon a time.

• 1802 Dr. Phillipp Bozzini Lichtleiter
• 1931 Dr. Micheal S. Burman
• 20 cadaveric hip joints

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First Clinical Application 1939

• Dr. Kenji Takagi
• 2 Charcot joints
• 1 Tbc arthritis
• 1 Supparative
• arthritis

J Jpn Orthop Assoc 1939
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Anatomy
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Hip Arthrogram
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Tip of Physical Exams

• Differential diagnosis to intra/extra-articular
  pain, pubic pain
• One joint above and below
• Gait LLD, pelvic obliquity
• foot-progression angle muscle contraction

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Impingement Sign
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Tip of Physical Exams

• Intra-articular lesion log rolling, McCarthy
  hip extension sign
• SI problem FABER test
• Hip flexion contracture Thomas test
• Piriformis syndrome sit active ER
• Hip dysplasia anterior apprehension test (
  extend ER)

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FABER Test
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Differential Diagnosis of Groin Pain
4 zones of groin pain
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Differential Diagnosis of Groin Pain
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Osteitis Pubis Soccer Player
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(No Transcript)
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F 20 yo. w/ hx of posterior dislocation for 4 y.
PTA
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CT scan
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3D-CT scan
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Disorders That May Benefit from Hip Arthroscopy
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Labral Tears
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Labral Tears

• Traumatic tears
• posterior hip dislocation
• pain/catching after twisting or slipping
• repetitive hyperflexion

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Labral Tears

• N. America 436 hips, 96 were anterior lesion
  (twist, pivot)
• McCarthy JC. JBJS Am May 2005

Asian hips were most postero-superior lesion
(hyperflex, squat) Ikeda T. JBJS Br June 1988
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MRI Labral Tears
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Labral Tears

• Degenerative tears
• OA hip
• relieve mechanical symptom in some pts
• did scope in early OA pts worsen outcome
• (Walton NP. Int Orthop June 2004)

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Arthroscopic Classification of Hip Labral Tears
Radial flap
Radial fibrillated
Lage LA. Arthroscopy Dec 1996.
Longitudinal
Complex
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Debridement of Labral Tears
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Arthroscopic Labral Repair
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Labral Tears

• Hip dysplasia
• selected patient
• literatures devoid of studies this patient
  population, open acetabular osteotomy remains
  reasonable well-described treatment
• shollow acetabulum subluxate
  distribute abnormal stress from a head on the
  labrum

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Chondral Lesions

• Lateral impact mechanism ( by GT)
• Associated labral tears 55.3
• (McCarthy JC. Clin Orthop 2001)
• Cartilage stimulation
• ACI
• Future more predictable cartilage-resurfacing
  procedure

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Chondral Flap Tear and Microfracture
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Labral Lesion with Chondral Lesion

• Subchondral cyst
• formation
• Synovial fluid
• burrows beneath
• the delaminating
• cartilage and
• subchondral bone

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Risk Factors of 2º OA from Labral Tears

• With developmental dysplasia
• Tears gt 5 years old
• Full-thickness chondral lesion

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Ligamentum Teres
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Ligamentum Teres Rupture

• Deep anterior groin pain
• Mechanical symptoms
• History of significant trauma
• Associated pathology labrum, LB, chondral
  damage
• ? Incidence
• (Byrd JWT. Arthroscopy April 2004)

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Ligamentum Teres Rupture
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Snapping Hip(Coxa Sultans Interna)
Iliopsoas bursitis
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Iliopsoas Tendon Release
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Iliopsoas Tendon Release
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Pipkin Fracture
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Loose Bodies Removal
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Synovial Abnormalities

• Chondromatosis
• Crystalline disease
• RA/SLE
• Ehler-Danlos
• capsular
• shrinkage

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Femoral Acetabular Impingement (FAI)

• Leads to OA hip
• anterior head-neck offset or acetabular
  overcoverage

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Radiographic Workup

• AP view
• Lateral view (Cross-table)
• Lateral view (Dunn, false-profile)

Alpha angle Control 42º FAI pt 74 º
(Notzli HP. JBJS Br March 2002)
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MRI coronal plain
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Cam Type

• Caused by shear forces of the non-spherical
  position of the head against the acetabulum
• Anterosuperior cartilage
• Predisposing factors SCFE, abnormal epiphyseal
  extension, malunion neck/head fracture, and
  femoral retroversion

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Cam Type
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Pincer Type

• Repetitive stresses of a normal neck against an
  abnormal acetabular rim (over-coverage)
• Antero-superior labrum coup
• Postero-inferior head contre-coup
• Predisposing factors acetabular
  protrusio/retroversion, malunion acetabulum, 2
  from osteotomy

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Pincer Type
Normal
Cross-over sign
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Mixed Type

• Combine head/cup
• lesions
• Less isolated type
• (Cam 9, Pincer 5)
• (Beck M. JBJS Br Jan 2005)

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Chilectomy (Osteochondroplasty)
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Arthroscopic Osteochondroplasty
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Arthroscopic Osteochondroplasty
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Osteonecrosis

• Limited role only in a good spherical head to map
  a chondral lesion
• Procedure before free fibular grafting/core
  decompression
• Reserved for mechanical symptoms

is still debating
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Other Indications

• Biopsy of lesions
• Synovectomy /
• bursectomy
• Diagnosis of pain
• Septic arthritis
• After THR

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What is this?
PVNS
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Contraindication

• Advanced arthritis
• Stiff hip
• Heterotopic ossification
• Severe dysplasia

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• A surgeon is just a regular doctor,
• with few special skills.
• Dr. B.F. Bryd, Jr.

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Equipments Set up
Fluoroscope
Fracture table
Well-padded booties
Perineal post
Well trained flu technicians
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Booties
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Standard Portals
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Peroneal Post or Bean Bag?

• Hip arthroscopy without a perineal post a
  safer technique for hip distraction
• Decrease risk of pudendal nerve palsy
• Deflated beanbag contoured around the flank and
  thorax
• (Merrell G. Arthroscopy Jan 2007 23(1)10)7)

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Traction Time

• Not more than 1-2 hrs
• The lesser time, the lower complication
• HA without traction
• peripheral lesions
• younger age pts

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Approach Techniques

• Supine

Lateral
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3 Common Portals

• Anterior portal
• Lateral portals
• - Lateral-anterior portal
• - Lateral-posterior portal

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Portals
Vulnerable structures



Landmark anterior portal
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Adequate Distraction
Distracted joint space 7-10 mm.
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Surgical Instruments
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Surgical Instruments
Spinal needle
Glick Arthrex Set Extra-long scopes both 30º and
70º
Nitinol wire
Cannulated obturator
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Common Steps

1. Peripheral area assessment
2. Do the labral or chonral procedures
3. Flex an affected hip 45º, release traction
4. Exam the L. teres lesion or osteo-chondroplasty
   (Chilectomy)
5. Move the leg check adequacy of cartilage/bony
   removal

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Complications

• 1.4-7
• sciatic and femoral neurapraxia (resolve in 2-3
  d)
• Perineal injury
• Portal bleeding
• Trochanteric bursitis
• Intra-articular instrument breakage

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Catastrophic Complications

• O.5 permanent
• (Sampson TG. Clin Sports Med 2001)
• Permanent sciatic and femoral nerve damage
• Femoral vascular injury
• Septic arthritis
• Cardiac arrest intra-abdominal extravasation
  of fluid (Acetabular fx)
• (Bartlett CS. J Orthop Trauma Dec 1998)

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Metallic Stain
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P R A Y F R J A P A N PRAY F
R RESIDENT RTHOPAEDIC RAMA