Application of
Hip Arthroscopy
Nadhaporn Saengpetch, MD.
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
Once upon a time….
• 1802 Dr. Phillipp
Bozzini “Lichtleiter”
• 1931 Dr. Micheal S.
Burman
20 cadaveric hip
joints
First Clinical Application : 1939
Dr. Kenji Takagi
2 Charcot joints
1 Tbc arthritis
1 Supparative
arthritis
J Jpn Orthop Assoc 1939
Anatomy
Hip Arthrogram
Tip of Physical Exams
• Differential diagnosis to intra/extraarticular pain, pubic pain
• One joint above and below
• Gait : LLD, pelvic obliquity
• foot-progression angle & muscle
contraction
Impingement Sign
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)
FABER Test
Differential Diagnosis of Groin
Pain
4 zones of groin pain
Differential Diagnosis of Groin
Pain
Osteitis Pubis : Soccer Player
F 20 yo. w/ hx of posterior
dislocation for 4 y. PTA
CT scan
3D-CT scan
Disorders That May Benefit from
Hip Arthroscopy
Labral Tears
Labral Tears
• Traumatic tears
posterior hip dislocation
pain/catching after twisting or
slipping
repetitive hyperflexion
Labral Tears
N. America : 436
hips, 96% were
anterior lesion
(twist, pivot)
McCarthy JC. JBJS
Am May 2005
Asian hips were
most posterosuperior lesion
(hyperflex, squat)
Ikeda T. JBJS
Br June 1988
MRI : Labral Tears
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)
Arthroscopic Classification of
Hip Labral Tears
*Radial flap
Longitudinal
Radial fibrillated
Complex
Lage LA.
Arthroscopy
Dec 1996.
Debridement of Labral Tears
Arthroscopic Labral Repair
Labral Tears
• Hip dysplasia
– selected patient
– literatures devoid of studies this
patient population, open acetabular
osteotomy remains reasonable & welldescribed treatment
– shollow acetabulum
subluxate &
distribute abnormal stress from a head
on the labrum
Chondral Lesions
• Lateral impact mechanism ( by GT)
• Associated labral tears 55.3%
(McCarthy JC. Clin Orthop 2001)
• Cartilage stimulation
• ACI
• Future : more predictable cartilageresurfacing procedure
Chondral Flap Tear and
Microfracture
Labral Lesion with Chondral
Lesion
•Subchondral cyst
formation
•Synovial fluid
burrows beneath
the delaminating
cartilage and
subchondral bone
Risk Factors of 2º OA from
Labral Tears
• With developmental dysplasia
• Tears > 5 years old
• Full-thickness chondral lesion
Ligamentum Teres
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)
Ligamentum Teres Rupture
Snapping Hip
(Coxa Sultans Interna)
Iliopsoas bursitis
Iliopsoas Tendon Release
Iliopsoas Tendon Release
Pipkin Fracture
Loose Bodies Removal
Synovial Abnormalities
• Chondromatosis
• Crystalline disease
• RA/SLE
• Ehler-Danlos :
capsular
shrinkage
Femoral Acetabular
Impingement (FAI)
• Leads to OA hip
• anterior head-neck offset or
acetabular overcoverage
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)
MRI : coronal plain
Cam Type
• Caused by shear forces of the nonspherical position of the head
against the acetabulum
• Anterosuperior cartilage
• Predisposing factors : SCFE,
abnormal epiphyseal extension,
malunion neck/head fracture, and
femoral retroversion
Cam Type
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
Pincer Type
Normal
Cross-over sign
Mixed Type
• Combine head/cup
lesions
• Less isolated type
(Cam 9%, Pincer 5%)
(Beck M. JBJS Br Jan 2005)
Chilectomy
(Osteochondroplasty)
Arthroscopic
Osteochondroplasty
Arthroscopic
Osteochondroplasty
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…”
Other Indications
• Biopsy of lesions
• Synovectomy /
bursectomy
• Diagnosis of pain
• Septic arthritis
• After THR
What is this?
PVNS
Contraindication
• Advanced arthritis
• Stiff hip
• Heterotopic ossification
• Severe dysplasia
“A surgeon is just a regular doctor,
with few special skills.”
Dr. B.F. Bryd, Jr.
Equipments Set up
Fracture table
Fluoroscope
Well-padded booties
Perineal post
Well trained flu technicians
Booties
Standard Portals
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)
Traction Time
• Not more than 1-2 hrs
• The lesser time, the lower
complication
• HA without traction
peripheral lesions
younger age pts
Approach Techniques
Supine
Lateral
3 Common Portals
1. Anterior portal
2. Lateral portals
- Lateral-anterior portal
- Lateral-posterior portal
Portals
*
*
*
Landmark : anterior portal
Vulnerable structures
Adequate Distraction
Distracted joint space 7-10 mm.
Surgical Instruments
Surgical Instruments
Spinal needle
Nitinol wire
Cannulated obturator
Glick Arthrex Set
Extra-long scopes
both 30º and 70º
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 osteochondroplasty (Chilectomy)
5. Move the leg : check adequacy of
cartilage/bony removal
Complications
• 1.4-7%
• sciatic and femoral neurapraxia*
(resolve in 2-3 d)
• Perineal injury
• Portal bleeding
• Trochanteric bursitis
• Intra-articular instrument breakage
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)
Metallic Stain
PRAY
PRAY F
F
R JAPAN
R RESIDENT
RTHOPAEDIC RAMA