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Arthroscopy of the Hip: 12 Years of Experience
Arthroscopy of the Hip: 12 Years of Experience Henri Dorfmann, M.D., and Thierry Boyer, M.D.
Summary: The purpose of this study was to evaluate the results of and temporal trends in hip arthroscopy by reviewing 413 procedures performed over a 12-year period. The two anatomic areas of the hip can be examined separately, the periphery without distraction and the iliofemoral joint per se with distraction. Combined use of both these techniques should be decided preoperatively. Technical explanations and a description of three clearly demarcated portal site areas are given to improve standardization of the hip arthroscopy technique. Diagnostic use of hip arthroscopy (undiagnosed hip pain, catching, or popping of the joint) accounted for 68% of all procedures in our series, although this proportion declined over time. The main indication for operative hip arthroscopy was removal of loose bodies. Debridement is an important indication reported in the literature, but it was not performed in our patients. Numerous other operative procedures can be done but are indicated in smaller numbers of patients. Key Words: Hip—Joint—Arthroscopy.
A
fter the first report of arthroscopy of the hip by Burman1 in 1931, several articles were published in the late 1970s,2-6 and more diverse series in the early 1980s.7-9 Nevertheless, this method has not yet gained widespread acceptance. The best technique and indications are not agreed on in the literature. We will provide data on both these points gathered during our 12 years of experience with hip arthroscopy. PATIENTS AND METHODS From January 1983 to the end of December 1995, we performed 413 hip arthroscopies in 395 patients (206 females and 189 males). The left hip was examined in 199 cases and the right hip in 214 cases. Mean patient age was 40.3 years (range, 14 to 81 years). Of the 14 patients who underwent more than one hip arthroscopy, 13 had chondromatosis of the hip.
From the Service de Rhumatologie, Centre Hospitalier Robert Ballanger, Aulnay Sous Bois, France. Address correspondence and reprint request to Henri Dorfmann, M.D., Service de Rhumatologie, Centre Hospitalier Robert Ballanger, 93602 Aulnay Sous Bois, France. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1501-1799$3.00/0
Technique Our first eight patients were examined via the anterior approach on a fracture table as described by Johnson.8 After this method was discontinued, 358 hip arthroscopies were done without and 47 with traction. Starting in July 1993, we used the mixed technique for all hip arthroscopies done with traction. Of the 413 hip arthroscopies, 254 (68%) were diagnostic and 159 (32%) were operative. Of the 47 procedures done with traction, 32 (68%) were operative. Mean time from symptom onset to arthroscopy (known in 222 patients) was 29 months (range, 15 days to 34 years). The distribution by calendar year of diagnostic and operative procedures and of procedures done with and without traction is shown in Fig 1. Table 1 shows the main diagnosis assigned at the end of each arthroscopic procedure. All main final diagnoses were made based on clinical, imaging study, laboratory, and, if needed, biopsy data. All 100 patients classified as having hip osteoarthritis had normal or small dysplastic hips on plain radiographs; arthroscopy showed stage III or IV chondropathy, usually focal, with mechanical synovitis, and magnetic resonance imaging (MRI) or computed arthrotomography consistently showed abnormalities suggestive of synovitis or loose bodies. The 14 cases in the chondropathy
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 1 (January-February), 1999: pp 67–72
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FIGURE 1.
Evaluation of goals and technique. (M) Therapeutic arthroscopy, (䊐) diagnostic arthroscopy, (–䊏–) arthroscopy with traction.
TABLE 1. Main Diagnosis of Each Hip Arthroscopy Diagnosis
No.
Osteoarthrosis Coxitis Chondropathy Mechanical synovitis synovitis Pigmented villonodular synovitis Septic arthritis Foreign bodies Labral lesion Chondromatosis Normal Anterior snapping Chondrocalcinosis Plicae Chondral fracture Aseptic necrosis Osteochondritis dissecans Capsulitis Unknown Post-traumatic synovitis Hemorragic synovitis Rapid destructive osteoarthritis of the hip Synovial cyst Ossification Ligamentum teres avulsion
100 24 10 22 14 3 7 18 103 55 17 4 5 3 2 3 4 6 2 5 2 1 1 2
group had arthroscopic findings of stage I or II chondropathy. All 24 cases of inflammatory hip disease were suspected based on the proliferative appearance noted at arthroscopy and were confirmed by a biopsy. Labral lesions are commonly overestimated at arthrography, and we made this diagnosis only in 18 cases with both degenerative and traumatic lesions. Ninety-three of the 103 arthroscopies done for chondromatosis were therapeutic (i.e., the diagnosis was made or suspected before arthroscopy). The number of cases with normal arthroscopy remained too high (n ⫽ 55), but decreased with experience and careful patient selection.
DISCUSSION Arthroscopic Anatomy In our opinion, the most important point is differentiation of the peripheral and iliofemoral areas, which to our knowledge has not been discussed in the literature, although three large studies of the arthroscopic anatomy of the hip have been published.10-12 In the peripheral area, the anterior and inferior aspects of the femoral neck can be readily visualized, with the important landmark of the pectineal-foveal
ARTHROSCOPY OF THE HIP ligament at the undersurface of the neck. The arthroscope can be moved upward from the anterior horn of the labrum to the upper pole, with a variable degree of posterior displacement as needed to allow visualization of the peripheral aspect and rim of the labrum. The most lateral portion of the endoarticular aspect is sometimes visible and can always be palpated using a hook. Part of the femoral head cartilage can be seen during flexion-extension, rotation, and abductionadduction of the hip. It is in the peripheral area that the synovial membrane is best visualized, down to its inferior recess. The second area is the iliofemoral joint per se, which includes the acetabular fossa, the ligamentum teres, the horseshoe cartilage, the capital cartilage, and the endoarticular aspect of the labrum. Technique In our view the distinction between these two anatomic areas allows to use two different techniques. In some indications, hip arthroscopy can be done on an ordinary table without traction using our anterolateral approach. This simple method allows one to visualize all the peripheral areas described above. However, distraction of the joint is needed to enter the iliofemoral joint per se. In a very small number of cases, the iliofemoral area can be visualized by manual separation of the joint surfaces (12 of 358 hips examined without distraction). We now always use the mixed technique for hip arthroscopies with traction. After positioning the patient on an orthopaedic table, we examine the peripheral area via the anterolateral approach, without traction. Traction is then started. The previous examination facilitates joint surface separation. An image intensifier is used to guide the introduction of the arthroscope via Glick’s20,21 middle supratrochanteric approach in most cases, and Glick’s anterior supratrochanteric approach in a minority of cases. Complete visualization of the joint sometimes requires use of more than one approach in a given patient. Use of a 70° arthroscope can allow to increase the field of view by a few degrees. However, the anteroinferior part of the head and labrum are difficult to visualize. Most of our patients were examined in the supine position on an ordinary table without traction. This method is not mentioned in most studies, although it has been recommended by Klapper and Silver.13 When traction is deemed necessary, most authors9,14-19 use the supine position on an orthopaedic table first recommended by Johnson.8 Glick20,21 was the first to advocate lateral decubitus with dynamometer-con-
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trolled traction, a technique that is used by some groups.22-24 Irrespective of patient position, many portals have been described in the literature. It is important to bear in mind that, given the depth of the hip joint, the direction of insertion is at least as important as the position of the portal. At least three portal site areas should be differentiated (Fig 2). The anterior area is bounded laterally by a vertical line traced from the anterosuperior iliac spine in the direction of the lower limb. Ide et al.19 use a portal in this area. This is the portal closest to the femoral blood vessels. Johnson8 recommends a site in this area. In our opinion, the portal described as anterolateral by Parisien25 is in the anterior area; this site is located cephalad to Johnson’s site, at the junction of the lateral boundary (near the femoral cutaneous nerve). In the book by Parisien,26 however, this same portal is described as being midway between the anterosuperior iliac spine and the anterior edge of the greater trochanter, which clearly places it in the anterolateral area. This is a telling illustration of the problems raised by the definition of cutaneous portal sites. The anterolateral area is lateral to the abovementioned vertical line and medial to a vertical line through the anterior edge of the greater trochanter. Our first portal is midway between these two vertical lines, on a horizontal line along the upper edge of the pubic symphysis.27 At this site, there is often a soft point that allows palpation of the femoral neck at the lateral edge of the sartorius muscle. This site is located caudad to the entry site recommended by Parisien.26 When needed (for a biopsy or an operative procedure), we perform a second incision 5 cm caudad to the first portal, on the same vertical line. The lateral area is located over the greater trochanter. The three portals described by Glick are located in this area.20,21 Gross5 used an obturator portal in children; we are not aware of any reports of use of this site in adults. Adverse Events In our series, there were no adverse events in the patients examined without traction. Under traction, scuffing of the cartilage occurred in a few cases. Scuffing remains possible during arthroscopy even when an image intensifier is used. Although scuff marks have no serious consequences, they can impair visualization of the joint. Compression of the pudendal nerve is the most severe complication of hip arthroscopy with traction. It is this complication that prompted Glick21 to recommend that the patient be positioned on
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FIGURE 2. Anterosuperior iliac spine (I), femoral blood vessel (V), great trochanter (T), anterior area (zone I), anterolateral area (zone II), lateral area (zone III).
the side. There were two cases of pudendal nerve compression in the first study by Locker and Beguin.9 The risk of pudendal nerve compression is emphasized in a recent review by Rodeo et al.28 and in an article by Funke and Munzinger.29 Our experience and data from the literature highlight the need for steps aimed at preventing this complication, such as careful control of the intensity and duration of the traction, and adequate protection of the main countertraction pressure point. Injury to the femoral cutaneous nerve can occur with the portal advocated by Parisien. Indications Prerequisite: Arthroscopy is obviously not an investigation suitable for routine use. A careful prearthroscopy evaluation is essential to determine the objective
of the investigation and the optimal technique for a diagnostic or operative hip arthroscopic procedure. In addition to a clinical evaluation and to laboratory tests selected based on the clinical findings, appropriate imaging of the joint is essential. An anteroposterior radiograph of the pelvis and any other projections that may be necessary should be obtained. Bone scanning is rarely revealing, because uptake abnormalities are nonspecific. Except in villonodular synovitis, MRI has been somewhat disappointing; however, technical advances and the development of arthro-MRI will perhaps improve the results of this method. In our series, computed tomography or computed arthrotomography, when indicated, was the investigation with the highest yield. However, false-positive results suggest-
ARTHROSCOPY OF THE HIP ing tears of the labrum can occur, and the interpretation of images of synovitis can be difficult. The distinction between chondromatosis and simple reactive synovitis or villonodular synovitis is not always easy. For all these reasons, its appears in our experience that there is still a place for. Diagnostic Hip Arthroscopy: We believe that diagnostic hip arthroscopy is indicated mainly in patients with one of the following two clinical presentations30,31: hip pain that remains undiagnosed despite all the above-mentioned investigations, and undiagnosed catching or locking of the hip. There is general agreement that hip arthroscopy is valuable as a diagnostic investigation, although the indications for this use of arthroscopy in the hip can be expected to decrease in the future as it has already done for other joints as a result of improvements in imaging techniques. Overall, 68% of the hip arthroscopies in our study were diagnostic. This proportion decreased steadily starting in the early 1990s, and in 1995 the proportion of diagnostic arthroscopies fell below that of operative arthroscopies for the first time (47.2% v 52.8%, Fig 1). Our indications are consistent with those in the literature.16,17,22,24,32 Diagnostic problems that can require arthroscopy include differentiation of incipient hip osteoarthritis from inflammatory hip disease, chondrocalcinosis, villonodular synovitis, or chondromatosis. Arthroscopic visualization of the cartilage, labrum, and synovial membrane, and above all examination of biopsy specimens harvested during arthroscopy can ensure the differential diagnosis between mechanical disease and inflammatory disease or any other type of arthropathy. In patients with catching or transient locking of the hip, intra-articular causes should be differentiated from extraarticular causes, particularly anteromedial catching.33 When this last diagnosis is suspected, the main objective of arthroscopy, when performed, is to rule out an intra-articular disease. Among the 17 patients with this diagnosis in our series, some had a small focus of synovitis, which may have been caused by impingement of the psoas muscle tendon on the anterior and anteroinferior aspect of the femoral neck. Most of our diagnostic arthroscopies were done without traction. Although modest iliofemoral lesions can be missed with this method, a peripheral synovial reaction is present in virtually every hip with a chronic abnormality. This is usually sufficient to establish the diagnosis, in conjunction with findings from a clinical evaluation and from imaging studies. We demonstrated the value of this attitude in an earlier study.34 Arthroscopy is of value in patients with lesions of the labrum.35-37 Degenerative lesions (which may be
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analogous to recognized meniscal lesions38 ) should be differentiated from traumatic lesions. Labral tears tend to be tag-like rather than massive. Risk factors are dysplasia of the hip, perhaps degenerative disease of the labrum, and mechanical stress due to overuse. Two of our patients had avulsion of the ligamentum teres without dislocation of the hip, a condition previously described during arthrotomy.39 Operative Hip Arthroscopy: As a result of recruitment bias, most of the operative arthroscopies in our series were done for removal of loose bodies in patients with chondromatosis, a diagnosis that accounted for only a few cases in earlier studies.40,41 According to the location of the loose bodies as determined on imaging studies, the arthroscopy is done with or without traction. Small loose bodies can be removed by simple joint lavage, whereas a forceps are needed to extract larger fragments. We do not have any experience with synovectomy in patients with sessile or pedunculated fragments. Removal of an isolated labral tag was performed in nine of our patients. A variety of loose bodies were removed (including in a patient with established osteoarthritis). We did not perform debridement for established osteoarthritis, although this procedure is strongly advocated in the earliest articles by Glick,20,21 as well as in reports by Vilar et al.42 and Hawkins et al.23 Given the promising results of debridement at the knee, this method deserves to be evaluated at the hip. However, a well-designed prospective study is needed to validate the use of debridement in hip osteoarthritis. We have no personal experience of arthroscopy in other conditions such as septic arthritis,43-45 extraction of a bullet,46 and removal of acrylic cement after total hip replacement.47-49 Snow et al.50 reported anterior impingement of the femoral head as a delayed complication of Perthes’ disease, and, in an earlier article, Bowen et al.51 emphasized the value of arthroscopy for osteochondritis dissecans. CONCLUSION We believe that arthroscopy is an excellent tool for investigating and treating various hip diseases. Adaptation to the goal is especially important at the hip. For example, if the synovium is to be investigated and biopsied, traction is unnecessary and potentially harmful. As a diagnostic procedure, hip arthroscopy remains useful in some cases, although its indications are decreasing as imaging studies improve. In contrast, the range of hip abnormalities that can be treated arthroscopically is increasing. Removal of loose bodies remains, however, the main therapeutic indication.
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Our limited experience with labral lesions and with partial synovectomy is encouraging. Hip arthroscopy is a safe method provided the indications, methods, and portals are selected carefully by an experienced operator. REFERENCES 1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg 1931;13:669-695. 2. Aignan M. L’arthroscopie de hanche ‘‘R’’ 1975;24. 3. Aignan M. Arthroscopy of the hip. ‘‘R’’ 1976;33:458. 4. Aignan M. La ponction biopsie synoviale de la hanche. Med Hygiene 1979;37:1153-1154. 5. Gross RH. Arthroscopy in hip disorders in children. Orthop Rev 1977;6:43-49. 6. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. Ed 3. Tokyo: Igaku-Shoin, 1957:145-146. 7. Holgersson S, Brattstr MH, Mogensen B, Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop 1981;1:273-278. 8. Johnson LL. Hip joint in diagnostic and surgical arthroscopy. Ed 2. St. Louis: Mosby, 1981;405-411. 9. Locker B, Beguin J. L’arthroscopie de hanche. J Med Lyon 1984;1394:25-26. 10. Byrd JWT, Pappas JN, Pedley MJ. Hip arthroscopy: An anatomic study of portal placement and relationship to the extra-articular structures. Arthroscopy 1995;11:418-423. 11. Dvorak M, Duncan CP, Day B. Arthroscopic anatomy of the hip. Arthroscopy 1990;6:264-273. 12. Keene GS, Villar RN. Arthroscopic anatomy of the hip: An in vivo study. Arthroscopy 1994;10:392-399. 13. Klapper RC, Silver DM. Hip arthroscopy without traction. Contemp Orthop 1989;18:687-693. 14. Anders S, Schreiner C, Grifka J. Ho¨fgelenkarthroskopie bein posttraumatischem Ho¨ftschermz. Arthroskopie 1994;7:80-82. 15. Byrd JWT. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280. 16. Eriksson E, Arvidsson I, Arvidsson NH. Diagnostic and operative arthroscopy of the hip. Orthopedics 1986;9:169-176. 17. Gondolph-Zink B. Aktueller stand der diagnostischen und operativen hftarthroskopie. Orthopede 1992;21:249-256. 18. Hoppert M, Hagena FW. Operative arthroskopie des Heftgelenks. Technik und bisherige erfahrungen. Arthroskopie 1994;7: 47-50. 19. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of the hip joint. Arthroscopy 1991;7:204-211. 20. Glick JM. Hip arthroscopy in operative arthroscopy. Mc Ginty JB, ed. New York: Raven, 1991;663-676. 21. Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E. Hip arthroscopy by the lateral approach. Arthroscopy 1987;3:4-12. 22. Funke EL, Munzinger U. Zur indikation und technik der Ho¨ftarthroskopie: Mo¨glichteiten und grenzen. Schweiz Rundschau Med 1994;83:154-157. 23. Hawkins RB. Arthroscopy of the hip. Clin Orthop 1989;249:4447. 24. Villar RN. Hip arthroscopy (editorial). J Bone Joint Surg Br 1995;77:517-518. 25. Parisien S. Arthroscopy of the hip. Present status. J Dis Orthop 1985;45:127-132. 26. Parisien S. Hip arthroscopy: Supine position. In: Parisien S, ed. Techniques in therapeutic arthroscopy. New York: Raven, 1993; chap 23. 27. Dorfmann H, Boyer T, Henry P, De Bie B. A simple approach to hip arthroscopy. Arthroscopy 1988;4:141-142.
28. Rodeo SA, Forster RA, Weiland AJ. Current concepts review: Neurological complications due to arthroscopy. J Bone Joint Surg Am 1993;75:917-926. 29. Funke EL, Munzinger U. Complications in hip arthroscopy. Arthroscopy 1996;12:156-159. 30. Dorfmann H. Arthroscopie de hanche. Press Med 1988;17:611612. 31. Dorfmann H, Boyer T, De Bie B. Arthroscopie de hanche. Rev Rhum 1988;55:33-36. 32. Frich LH, Lauritzen J, Juhl M. Arthroscopy in diagnosis and treatment of hip disorders. Orthopedics 1989;12:389-392. 33. Kouvalchouk JF, Durey A, Paszkowski A, Watin-Augouard L. Les ressauts ante´rieurs de hanche. J Traumatol Sport 1989;6: 171-176. 34. Dorfmann H, Boyer T, De Bie B. Arthroscopie de hanche— Me´thodes et inte´reˆt. Rev Rhum 1993;60:330-334. 35. Dorfmann H. Pathologie du bourrelet cotyloı¨dien. VIe`mes Journe´es de Me´decine et de Re´e´ducation de l’Est Parisien, 1995. 36. Locker B, Chiron P, Dorfmann H, Kelberine F. Arthroscopie de hanche. Confe´rence d’enseignement SFA. Annales de la SFA, 1992, 2, p. 74-97. Compte-rendu in Rev Chir Orthop 1993;79: 327-329. 37. Suzuki S, Awaya G, Okada Y, Maekawa M, Ikeda T, Tada H. Arthroscopic diagnosis of ruptured acetabular labrum. Acta Orthop Scand 1986;57:513-515. 38. Dorfmann H, Juan LH, Bonvarlet JP, Boyer T. Le´sion de´ge´ne´rative du me´nisque interne en arthroscopie. Classification et traitement. Rev Rhum 1987;54:303-310. 39. Delcamp DD, Klaaren HE, Pompe van Meerdervoort HF. Traumatic avulsion of the ligamentum teres without dislocation of the hip. J Bone Joint Surg Am 1988;70:933-935. 40. Okada Y, Awaya G, Ikeda T, Tada H, Kamisato S, Futami T. Arthroscopic surgery for synovial chondromatosis of the hip. J Bone Joint Surg Br 1989;71:198-199. 41. Witwity T, Uhlmann RD, Fischer J. Arthroscopic management of chondromatosis of the hip joint. Arthroscopy 1988;4:55-56. 42. Villar RN. Arthroscopic debridement of the hip. J Bone Joint Surg Br 1991;73:170-171 (suppl II). 43. Blitzer CM. Arthroscopic management of septic arthritis of the hip. Arthroscopy 1993;9:414-416. 44. Bould M, Edwards D, Villar RN. Arthroscopic diagnosis and treatment of septic arthritis of the hip joint. Arthroscopy 1993;9:707-708. 45. Chung WK, Slater GL, Bates EH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993;13:444446. 46. Goldman A, Minkoff J, Price A, Krinick R. A posterior arthroscopic approach to bullet extraction from the hip. J Trauma 1987;27:1294-1300. 47. Mah ET, Bradley CM. Arthroscopic removal of acrylic cement from unreduced hip prosthesis. Aust NZ J Surg 1992;62:508510. 48. Nordt W, Giangarra CE, Levy I, Habermann ET. Arthroscopic removal of entrapped debris following dislocation of a total hip arthroplasty. Arthroscopy 1987;3:196-198. 49. Shifrin LZ, Reis ND. Arthroscopy of a dislocated hip replacement: A case report. Clin Orthop 1978;6:213-214. 50. Snow SW, Keret D, Scarangella S, Bowen JR. Anterior impingement of the femoral head: A late phenomenon of Legg-Calve´-Perthes’ disease. J Pediatr Orthop 1993;13:286289. 51. Bowen JR, Kumar VP, Joyce JJ III, Bowen JC. Osteochondritis dissecans following Perthes’ disease. Arthroscopic operative treatment. Clin Orthop 1986;209:49-56.
Summary: The purpose of this study was to evaluate the results of and temporal trends in hip arthroscopy by reviewing 413 procedures performed over a 12-year period. The two anatomic areas of the hip can be examined separately, the periphery without distraction and the iliofemoral joint per se with distraction. Combined use of both these techniques should be decided preoperatively. Technical explanations and a description of three clearly demarcated portal site areas are given to improve standardization of the hip arthroscopy technique. Diagnostic use of hip arthroscopy (undiagnosed hip pain, catching, or popping of the joint) accounted for 68% of all procedures in our series, although this proportion declined over time. The main indication for operative hip arthroscopy was removal of loose bodies. Debridement is an important indication reported in the literature, but it was not performed in our patients. Numerous other operative procedures can be done but are indicated in smaller numbers of patients. Key Words: Hip—Joint—Arthroscopy.
A
fter the first report of arthroscopy of the hip by Burman1 in 1931, several articles were published in the late 1970s,2-6 and more diverse series in the early 1980s.7-9 Nevertheless, this method has not yet gained widespread acceptance. The best technique and indications are not agreed on in the literature. We will provide data on both these points gathered during our 12 years of experience with hip arthroscopy. PATIENTS AND METHODS From January 1983 to the end of December 1995, we performed 413 hip arthroscopies in 395 patients (206 females and 189 males). The left hip was examined in 199 cases and the right hip in 214 cases. Mean patient age was 40.3 years (range, 14 to 81 years). Of the 14 patients who underwent more than one hip arthroscopy, 13 had chondromatosis of the hip.
From the Service de Rhumatologie, Centre Hospitalier Robert Ballanger, Aulnay Sous Bois, France. Address correspondence and reprint request to Henri Dorfmann, M.D., Service de Rhumatologie, Centre Hospitalier Robert Ballanger, 93602 Aulnay Sous Bois, France. r 1999 by the Arthroscopy Association of North America 0749-8063/99/1501-1799$3.00/0
Technique Our first eight patients were examined via the anterior approach on a fracture table as described by Johnson.8 After this method was discontinued, 358 hip arthroscopies were done without and 47 with traction. Starting in July 1993, we used the mixed technique for all hip arthroscopies done with traction. Of the 413 hip arthroscopies, 254 (68%) were diagnostic and 159 (32%) were operative. Of the 47 procedures done with traction, 32 (68%) were operative. Mean time from symptom onset to arthroscopy (known in 222 patients) was 29 months (range, 15 days to 34 years). The distribution by calendar year of diagnostic and operative procedures and of procedures done with and without traction is shown in Fig 1. Table 1 shows the main diagnosis assigned at the end of each arthroscopic procedure. All main final diagnoses were made based on clinical, imaging study, laboratory, and, if needed, biopsy data. All 100 patients classified as having hip osteoarthritis had normal or small dysplastic hips on plain radiographs; arthroscopy showed stage III or IV chondropathy, usually focal, with mechanical synovitis, and magnetic resonance imaging (MRI) or computed arthrotomography consistently showed abnormalities suggestive of synovitis or loose bodies. The 14 cases in the chondropathy
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 15, No 1 (January-February), 1999: pp 67–72
67
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H. DORFMANN AND T. BOYER
FIGURE 1.
Evaluation of goals and technique. (M) Therapeutic arthroscopy, (䊐) diagnostic arthroscopy, (–䊏–) arthroscopy with traction.
TABLE 1. Main Diagnosis of Each Hip Arthroscopy Diagnosis
No.
Osteoarthrosis Coxitis Chondropathy Mechanical synovitis synovitis Pigmented villonodular synovitis Septic arthritis Foreign bodies Labral lesion Chondromatosis Normal Anterior snapping Chondrocalcinosis Plicae Chondral fracture Aseptic necrosis Osteochondritis dissecans Capsulitis Unknown Post-traumatic synovitis Hemorragic synovitis Rapid destructive osteoarthritis of the hip Synovial cyst Ossification Ligamentum teres avulsion
100 24 10 22 14 3 7 18 103 55 17 4 5 3 2 3 4 6 2 5 2 1 1 2
group had arthroscopic findings of stage I or II chondropathy. All 24 cases of inflammatory hip disease were suspected based on the proliferative appearance noted at arthroscopy and were confirmed by a biopsy. Labral lesions are commonly overestimated at arthrography, and we made this diagnosis only in 18 cases with both degenerative and traumatic lesions. Ninety-three of the 103 arthroscopies done for chondromatosis were therapeutic (i.e., the diagnosis was made or suspected before arthroscopy). The number of cases with normal arthroscopy remained too high (n ⫽ 55), but decreased with experience and careful patient selection.
DISCUSSION Arthroscopic Anatomy In our opinion, the most important point is differentiation of the peripheral and iliofemoral areas, which to our knowledge has not been discussed in the literature, although three large studies of the arthroscopic anatomy of the hip have been published.10-12 In the peripheral area, the anterior and inferior aspects of the femoral neck can be readily visualized, with the important landmark of the pectineal-foveal
ARTHROSCOPY OF THE HIP ligament at the undersurface of the neck. The arthroscope can be moved upward from the anterior horn of the labrum to the upper pole, with a variable degree of posterior displacement as needed to allow visualization of the peripheral aspect and rim of the labrum. The most lateral portion of the endoarticular aspect is sometimes visible and can always be palpated using a hook. Part of the femoral head cartilage can be seen during flexion-extension, rotation, and abductionadduction of the hip. It is in the peripheral area that the synovial membrane is best visualized, down to its inferior recess. The second area is the iliofemoral joint per se, which includes the acetabular fossa, the ligamentum teres, the horseshoe cartilage, the capital cartilage, and the endoarticular aspect of the labrum. Technique In our view the distinction between these two anatomic areas allows to use two different techniques. In some indications, hip arthroscopy can be done on an ordinary table without traction using our anterolateral approach. This simple method allows one to visualize all the peripheral areas described above. However, distraction of the joint is needed to enter the iliofemoral joint per se. In a very small number of cases, the iliofemoral area can be visualized by manual separation of the joint surfaces (12 of 358 hips examined without distraction). We now always use the mixed technique for hip arthroscopies with traction. After positioning the patient on an orthopaedic table, we examine the peripheral area via the anterolateral approach, without traction. Traction is then started. The previous examination facilitates joint surface separation. An image intensifier is used to guide the introduction of the arthroscope via Glick’s20,21 middle supratrochanteric approach in most cases, and Glick’s anterior supratrochanteric approach in a minority of cases. Complete visualization of the joint sometimes requires use of more than one approach in a given patient. Use of a 70° arthroscope can allow to increase the field of view by a few degrees. However, the anteroinferior part of the head and labrum are difficult to visualize. Most of our patients were examined in the supine position on an ordinary table without traction. This method is not mentioned in most studies, although it has been recommended by Klapper and Silver.13 When traction is deemed necessary, most authors9,14-19 use the supine position on an orthopaedic table first recommended by Johnson.8 Glick20,21 was the first to advocate lateral decubitus with dynamometer-con-
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trolled traction, a technique that is used by some groups.22-24 Irrespective of patient position, many portals have been described in the literature. It is important to bear in mind that, given the depth of the hip joint, the direction of insertion is at least as important as the position of the portal. At least three portal site areas should be differentiated (Fig 2). The anterior area is bounded laterally by a vertical line traced from the anterosuperior iliac spine in the direction of the lower limb. Ide et al.19 use a portal in this area. This is the portal closest to the femoral blood vessels. Johnson8 recommends a site in this area. In our opinion, the portal described as anterolateral by Parisien25 is in the anterior area; this site is located cephalad to Johnson’s site, at the junction of the lateral boundary (near the femoral cutaneous nerve). In the book by Parisien,26 however, this same portal is described as being midway between the anterosuperior iliac spine and the anterior edge of the greater trochanter, which clearly places it in the anterolateral area. This is a telling illustration of the problems raised by the definition of cutaneous portal sites. The anterolateral area is lateral to the abovementioned vertical line and medial to a vertical line through the anterior edge of the greater trochanter. Our first portal is midway between these two vertical lines, on a horizontal line along the upper edge of the pubic symphysis.27 At this site, there is often a soft point that allows palpation of the femoral neck at the lateral edge of the sartorius muscle. This site is located caudad to the entry site recommended by Parisien.26 When needed (for a biopsy or an operative procedure), we perform a second incision 5 cm caudad to the first portal, on the same vertical line. The lateral area is located over the greater trochanter. The three portals described by Glick are located in this area.20,21 Gross5 used an obturator portal in children; we are not aware of any reports of use of this site in adults. Adverse Events In our series, there were no adverse events in the patients examined without traction. Under traction, scuffing of the cartilage occurred in a few cases. Scuffing remains possible during arthroscopy even when an image intensifier is used. Although scuff marks have no serious consequences, they can impair visualization of the joint. Compression of the pudendal nerve is the most severe complication of hip arthroscopy with traction. It is this complication that prompted Glick21 to recommend that the patient be positioned on
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FIGURE 2. Anterosuperior iliac spine (I), femoral blood vessel (V), great trochanter (T), anterior area (zone I), anterolateral area (zone II), lateral area (zone III).
the side. There were two cases of pudendal nerve compression in the first study by Locker and Beguin.9 The risk of pudendal nerve compression is emphasized in a recent review by Rodeo et al.28 and in an article by Funke and Munzinger.29 Our experience and data from the literature highlight the need for steps aimed at preventing this complication, such as careful control of the intensity and duration of the traction, and adequate protection of the main countertraction pressure point. Injury to the femoral cutaneous nerve can occur with the portal advocated by Parisien. Indications Prerequisite: Arthroscopy is obviously not an investigation suitable for routine use. A careful prearthroscopy evaluation is essential to determine the objective
of the investigation and the optimal technique for a diagnostic or operative hip arthroscopic procedure. In addition to a clinical evaluation and to laboratory tests selected based on the clinical findings, appropriate imaging of the joint is essential. An anteroposterior radiograph of the pelvis and any other projections that may be necessary should be obtained. Bone scanning is rarely revealing, because uptake abnormalities are nonspecific. Except in villonodular synovitis, MRI has been somewhat disappointing; however, technical advances and the development of arthro-MRI will perhaps improve the results of this method. In our series, computed tomography or computed arthrotomography, when indicated, was the investigation with the highest yield. However, false-positive results suggest-
ARTHROSCOPY OF THE HIP ing tears of the labrum can occur, and the interpretation of images of synovitis can be difficult. The distinction between chondromatosis and simple reactive synovitis or villonodular synovitis is not always easy. For all these reasons, its appears in our experience that there is still a place for. Diagnostic Hip Arthroscopy: We believe that diagnostic hip arthroscopy is indicated mainly in patients with one of the following two clinical presentations30,31: hip pain that remains undiagnosed despite all the above-mentioned investigations, and undiagnosed catching or locking of the hip. There is general agreement that hip arthroscopy is valuable as a diagnostic investigation, although the indications for this use of arthroscopy in the hip can be expected to decrease in the future as it has already done for other joints as a result of improvements in imaging techniques. Overall, 68% of the hip arthroscopies in our study were diagnostic. This proportion decreased steadily starting in the early 1990s, and in 1995 the proportion of diagnostic arthroscopies fell below that of operative arthroscopies for the first time (47.2% v 52.8%, Fig 1). Our indications are consistent with those in the literature.16,17,22,24,32 Diagnostic problems that can require arthroscopy include differentiation of incipient hip osteoarthritis from inflammatory hip disease, chondrocalcinosis, villonodular synovitis, or chondromatosis. Arthroscopic visualization of the cartilage, labrum, and synovial membrane, and above all examination of biopsy specimens harvested during arthroscopy can ensure the differential diagnosis between mechanical disease and inflammatory disease or any other type of arthropathy. In patients with catching or transient locking of the hip, intra-articular causes should be differentiated from extraarticular causes, particularly anteromedial catching.33 When this last diagnosis is suspected, the main objective of arthroscopy, when performed, is to rule out an intra-articular disease. Among the 17 patients with this diagnosis in our series, some had a small focus of synovitis, which may have been caused by impingement of the psoas muscle tendon on the anterior and anteroinferior aspect of the femoral neck. Most of our diagnostic arthroscopies were done without traction. Although modest iliofemoral lesions can be missed with this method, a peripheral synovial reaction is present in virtually every hip with a chronic abnormality. This is usually sufficient to establish the diagnosis, in conjunction with findings from a clinical evaluation and from imaging studies. We demonstrated the value of this attitude in an earlier study.34 Arthroscopy is of value in patients with lesions of the labrum.35-37 Degenerative lesions (which may be
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analogous to recognized meniscal lesions38 ) should be differentiated from traumatic lesions. Labral tears tend to be tag-like rather than massive. Risk factors are dysplasia of the hip, perhaps degenerative disease of the labrum, and mechanical stress due to overuse. Two of our patients had avulsion of the ligamentum teres without dislocation of the hip, a condition previously described during arthrotomy.39 Operative Hip Arthroscopy: As a result of recruitment bias, most of the operative arthroscopies in our series were done for removal of loose bodies in patients with chondromatosis, a diagnosis that accounted for only a few cases in earlier studies.40,41 According to the location of the loose bodies as determined on imaging studies, the arthroscopy is done with or without traction. Small loose bodies can be removed by simple joint lavage, whereas a forceps are needed to extract larger fragments. We do not have any experience with synovectomy in patients with sessile or pedunculated fragments. Removal of an isolated labral tag was performed in nine of our patients. A variety of loose bodies were removed (including in a patient with established osteoarthritis). We did not perform debridement for established osteoarthritis, although this procedure is strongly advocated in the earliest articles by Glick,20,21 as well as in reports by Vilar et al.42 and Hawkins et al.23 Given the promising results of debridement at the knee, this method deserves to be evaluated at the hip. However, a well-designed prospective study is needed to validate the use of debridement in hip osteoarthritis. We have no personal experience of arthroscopy in other conditions such as septic arthritis,43-45 extraction of a bullet,46 and removal of acrylic cement after total hip replacement.47-49 Snow et al.50 reported anterior impingement of the femoral head as a delayed complication of Perthes’ disease, and, in an earlier article, Bowen et al.51 emphasized the value of arthroscopy for osteochondritis dissecans. CONCLUSION We believe that arthroscopy is an excellent tool for investigating and treating various hip diseases. Adaptation to the goal is especially important at the hip. For example, if the synovium is to be investigated and biopsied, traction is unnecessary and potentially harmful. As a diagnostic procedure, hip arthroscopy remains useful in some cases, although its indications are decreasing as imaging studies improve. In contrast, the range of hip abnormalities that can be treated arthroscopically is increasing. Removal of loose bodies remains, however, the main therapeutic indication.
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Our limited experience with labral lesions and with partial synovectomy is encouraging. Hip arthroscopy is a safe method provided the indications, methods, and portals are selected carefully by an experienced operator. REFERENCES 1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg 1931;13:669-695. 2. Aignan M. L’arthroscopie de hanche ‘‘R’’ 1975;24. 3. Aignan M. Arthroscopy of the hip. ‘‘R’’ 1976;33:458. 4. Aignan M. La ponction biopsie synoviale de la hanche. Med Hygiene 1979;37:1153-1154. 5. Gross RH. Arthroscopy in hip disorders in children. Orthop Rev 1977;6:43-49. 6. Watanabe M, Takeda S, Ikeuchi H. Atlas of arthroscopy. Ed 3. Tokyo: Igaku-Shoin, 1957:145-146. 7. Holgersson S, Brattstr MH, Mogensen B, Lidgren L. Arthroscopy of the hip in juvenile chronic arthritis. J Pediatr Orthop 1981;1:273-278. 8. Johnson LL. Hip joint in diagnostic and surgical arthroscopy. Ed 2. St. Louis: Mosby, 1981;405-411. 9. Locker B, Beguin J. L’arthroscopie de hanche. J Med Lyon 1984;1394:25-26. 10. Byrd JWT, Pappas JN, Pedley MJ. Hip arthroscopy: An anatomic study of portal placement and relationship to the extra-articular structures. Arthroscopy 1995;11:418-423. 11. Dvorak M, Duncan CP, Day B. Arthroscopic anatomy of the hip. Arthroscopy 1990;6:264-273. 12. Keene GS, Villar RN. Arthroscopic anatomy of the hip: An in vivo study. Arthroscopy 1994;10:392-399. 13. Klapper RC, Silver DM. Hip arthroscopy without traction. Contemp Orthop 1989;18:687-693. 14. Anders S, Schreiner C, Grifka J. Ho¨fgelenkarthroskopie bein posttraumatischem Ho¨ftschermz. Arthroskopie 1994;7:80-82. 15. Byrd JWT. Hip arthroscopy utilizing the supine position. Arthroscopy 1994;10:275-280. 16. Eriksson E, Arvidsson I, Arvidsson NH. Diagnostic and operative arthroscopy of the hip. Orthopedics 1986;9:169-176. 17. Gondolph-Zink B. Aktueller stand der diagnostischen und operativen hftarthroskopie. Orthopede 1992;21:249-256. 18. Hoppert M, Hagena FW. Operative arthroskopie des Heftgelenks. Technik und bisherige erfahrungen. Arthroskopie 1994;7: 47-50. 19. Ide T, Akamatsu N, Nakajima I. Arthroscopic surgery of the hip joint. Arthroscopy 1991;7:204-211. 20. Glick JM. Hip arthroscopy in operative arthroscopy. Mc Ginty JB, ed. New York: Raven, 1991;663-676. 21. Glick JM, Sampson TG, Gordon RB, Behr JT, Schmidt E. Hip arthroscopy by the lateral approach. Arthroscopy 1987;3:4-12. 22. Funke EL, Munzinger U. Zur indikation und technik der Ho¨ftarthroskopie: Mo¨glichteiten und grenzen. Schweiz Rundschau Med 1994;83:154-157. 23. Hawkins RB. Arthroscopy of the hip. Clin Orthop 1989;249:4447. 24. Villar RN. Hip arthroscopy (editorial). J Bone Joint Surg Br 1995;77:517-518. 25. Parisien S. Arthroscopy of the hip. Present status. J Dis Orthop 1985;45:127-132. 26. Parisien S. Hip arthroscopy: Supine position. In: Parisien S, ed. Techniques in therapeutic arthroscopy. New York: Raven, 1993; chap 23. 27. Dorfmann H, Boyer T, Henry P, De Bie B. A simple approach to hip arthroscopy. Arthroscopy 1988;4:141-142.
28. Rodeo SA, Forster RA, Weiland AJ. Current concepts review: Neurological complications due to arthroscopy. J Bone Joint Surg Am 1993;75:917-926. 29. Funke EL, Munzinger U. Complications in hip arthroscopy. Arthroscopy 1996;12:156-159. 30. Dorfmann H. Arthroscopie de hanche. Press Med 1988;17:611612. 31. Dorfmann H, Boyer T, De Bie B. Arthroscopie de hanche. Rev Rhum 1988;55:33-36. 32. Frich LH, Lauritzen J, Juhl M. Arthroscopy in diagnosis and treatment of hip disorders. Orthopedics 1989;12:389-392. 33. Kouvalchouk JF, Durey A, Paszkowski A, Watin-Augouard L. Les ressauts ante´rieurs de hanche. J Traumatol Sport 1989;6: 171-176. 34. Dorfmann H, Boyer T, De Bie B. Arthroscopie de hanche— Me´thodes et inte´reˆt. Rev Rhum 1993;60:330-334. 35. Dorfmann H. Pathologie du bourrelet cotyloı¨dien. VIe`mes Journe´es de Me´decine et de Re´e´ducation de l’Est Parisien, 1995. 36. Locker B, Chiron P, Dorfmann H, Kelberine F. Arthroscopie de hanche. Confe´rence d’enseignement SFA. Annales de la SFA, 1992, 2, p. 74-97. Compte-rendu in Rev Chir Orthop 1993;79: 327-329. 37. Suzuki S, Awaya G, Okada Y, Maekawa M, Ikeda T, Tada H. Arthroscopic diagnosis of ruptured acetabular labrum. Acta Orthop Scand 1986;57:513-515. 38. Dorfmann H, Juan LH, Bonvarlet JP, Boyer T. Le´sion de´ge´ne´rative du me´nisque interne en arthroscopie. Classification et traitement. Rev Rhum 1987;54:303-310. 39. Delcamp DD, Klaaren HE, Pompe van Meerdervoort HF. Traumatic avulsion of the ligamentum teres without dislocation of the hip. J Bone Joint Surg Am 1988;70:933-935. 40. Okada Y, Awaya G, Ikeda T, Tada H, Kamisato S, Futami T. Arthroscopic surgery for synovial chondromatosis of the hip. J Bone Joint Surg Br 1989;71:198-199. 41. Witwity T, Uhlmann RD, Fischer J. Arthroscopic management of chondromatosis of the hip joint. Arthroscopy 1988;4:55-56. 42. Villar RN. Arthroscopic debridement of the hip. J Bone Joint Surg Br 1991;73:170-171 (suppl II). 43. Blitzer CM. Arthroscopic management of septic arthritis of the hip. Arthroscopy 1993;9:414-416. 44. Bould M, Edwards D, Villar RN. Arthroscopic diagnosis and treatment of septic arthritis of the hip joint. Arthroscopy 1993;9:707-708. 45. Chung WK, Slater GL, Bates EH. Treatment of septic arthritis of the hip by arthroscopic lavage. J Pediatr Orthop 1993;13:444446. 46. Goldman A, Minkoff J, Price A, Krinick R. A posterior arthroscopic approach to bullet extraction from the hip. J Trauma 1987;27:1294-1300. 47. Mah ET, Bradley CM. Arthroscopic removal of acrylic cement from unreduced hip prosthesis. Aust NZ J Surg 1992;62:508510. 48. Nordt W, Giangarra CE, Levy I, Habermann ET. Arthroscopic removal of entrapped debris following dislocation of a total hip arthroplasty. Arthroscopy 1987;3:196-198. 49. Shifrin LZ, Reis ND. Arthroscopy of a dislocated hip replacement: A case report. Clin Orthop 1978;6:213-214. 50. Snow SW, Keret D, Scarangella S, Bowen JR. Anterior impingement of the femoral head: A late phenomenon of Legg-Calve´-Perthes’ disease. J Pediatr Orthop 1993;13:286289. 51. Bowen JR, Kumar VP, Joyce JJ III, Bowen JC. Osteochondritis dissecans following Perthes’ disease. Arthroscopic operative treatment. Clin Orthop 1986;209:49-56.