Hip arthroscopy: Indications, outcomes and complications

Accepted Manuscript Hip arthroscopy: Indications, outcomes and complications Mujahid Jamil, Wael Dandachli, Shahryar Noordin, Johan Witt PII:

S1743-9191(17)31216-5

DOI:

10.1016/j.ijsu.2017.08.557

Reference:

IJSU 4095

To appear in:

International Journal of Surgery

Received Date: 20 February 2017 Revised Date:

28 July 2017

Accepted Date: 16 August 2017

Please cite this article as: Jamil M, Dandachli W, Noordin S, Witt J, Hip arthroscopy: Indications, outcomes and complications, International Journal of Surgery (2017), doi: 10.1016/j.ijsu.2017.08.557. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Hip Arthroscopy: Indications, Outcomes and Complications Corresponding / First Author:

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Dr Mujahid Jamil FCPS-Orth. FRCS-Orth. Assistant Professor, Aga Khan University Hospital, Karachi, Pakistan Second Author:

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Wael Dandachli

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BSc, MBBCh, PhD, FRCS-Orth. Consultant Orthopedic Surgeon, University College London Hospitals

Third Author:

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Last Author:

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Dr Shahryar Noordin FCPS-Orth. Associate Professor Associate Professor, Aga Khan University Hospital, Karachi, Pakistan

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Johan Witt FRCS-Orth. Consultant Orthopedic Surgeon, University College London Hospitals

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Hip Arthroscopy: Indications, Outcomes and Complications ABSTRACT Hip arthroscopy has recently occupied an important place in the armamentarium of General

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Orthopedic and especially hip surgeons. It is an effective and innovative procedure with rapidly expanding indications. Advancements in surgical tools and refinement in techniques

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has revolutionalized modern Hip arthroscopy. Surgeons are now able to address pathology in and around the hip joint that was either misdiagnosed or poorly understood. The

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procedure allows detailed visualization of acetabular labrum, femoral and acetabular chondral surfaces, fovea, ligamentum teres, synovium and the extra-articular peritrochanteric space. Minimally invasive surgery is now performed for diagnoses as well as treatment of a variety of Hip disorders. The acceptance and rates of hip arthroscopy are

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increasing across the board and the associated literature is expanding every day. Increasing surgical experience and improving technology is contributing for more advanced procedures to become popularized, however long-term outcome data about hip arthroscopy is still

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relatively sparse. We aim to review hip arthroscopy in the light of recent literature and will

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discuss the current indications, outcomes and complications of the procedure. INTRODUCTION

The first reported hip arthroscopy was performed on cadavers and is credited to M Burman (1931)1. Takagi in 1939 reported first clinical application of hip arthroscopy2. Further reports were limited until early 1980s when a plethora of papers came into print3. The indications expanded rapidly from intra-articular pathology in native hip joint to peritrochanteric space disorders, Trauma, hip snapping, pediatric hip disorders and in the assessment of painful

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ACCEPTED MANUSCRIPT total joint arthroplasty. With refinements in technique and experience, the role of hip arthroscopy continues to evolve and is gaining widespread familiarity.

1. FEMORO-ACETABULAR IMPINGEMENT (FAI):

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INDICATIONS AND OUTCOMES

Femoro-acetabular impingement has been described recently as a common cause of hip

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pain in young adults4-6 and is proposed as a cause of hip osteoarthritis 7-9. Impingement occurs as a result of abnormal contact between acetabular rim and proximal femur during

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hip movements. With normal anatomy there is enough space for clearance between acetabular rim and femoral head neck junction. The presence of a reduced head -neck offset (Cam type) 10 or acetabular over coverage (pincer type) 11, 12 leads to mechanical impingement with hip symptoms.

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Plane radiographs have limited value in the diagnosis of impingement 13. Furthermore, radiological features of impingement are recognised in asymptomatic hips14, 15. MRI arthrography is the investigation of choice for labral and chondral pathology but even high

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contrast Gadolinium enhanced arthrography is not entirely sensitive or specific for the

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diagnosis of these lesions16, 17. Arthroscopy enables dynamic and accurate assessment and is emerging as gold standard. Ganz et al described open surgical dislocation for impingement which allows the surgeon to correct the abnormal femoral head-neck junction without risk of osteonecrosis18. This technique is well established. It allows direct vision of the cartilage and labrum and the clearance of impingement is relatively straightforward. The main disadvantage is prolonged

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ACCEPTED MANUSCRIPT rehabilitation with exposure of articular cartilage to air and possibility of trochanteric fixation failure.

Hip arthroscopy is an attractive alternative and is becoming more familiar. The procedure is minimally invasive, offers a quicker recovery and excludes trochanteric non-union.

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Disadvantages include steep learning curve, potential dangers of hip traction and difficulty of evaluating the impingement during the procedure. Although no prospective clinical

comparison of arthroscopy with open technique is available, hip arthroscopy has proven

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effective in many series 19-21. When comparing surgical precision, no statistically significant

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differences were reported between the open and arthroscopic procedures in a cadaveric study22. Precise clearance of the impingement lesion uniformly results in a good outcome; however, an advanced degenerative change in the hip is a poor prognostic sign23. The debate for labral debridement versus repair continues to evolve. While Labral

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debridement alone has been reported effective in many series24, 25, some studies have reported that Labral repair is better than debridement alone 26, 27, 28. Whether repair is

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better for long term prevention of symptoms and/or arthritis, the answer is still awaited. Treating the abnormal morphology of the hip is however of paramount importance. With

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osseous abnormality left untreated, favourable outcome is less likely29, 30. Overall, hip arthroscopy offers a minimally invasive and effective treatment for Femoroacetabular impingement with some limitations. Resection of the cam lesion can be difficult if extending posteriorly, and over-or under-resection can result. Acetabular abnormalities are more difficult to treat. Acetabular rim trimming for pincer impingement traditionally requires initial labral take down, rim trimming and labral re-attachment. Alternatively some surgeons approach the overhanging rim from the capsule-labral sulcus and reflect and

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ACCEPTED MANUSCRIPT attach the labrum superiorly without taking it down. The arthroscopic approach to this procedure is technically demanding. Newer instrumentation and methods, surgeons

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experience and use of fluoroscopy is proving helpful31, 32.

2. TROCHANTERIC PAIN SYNDROME AND SNAPPING HIP DISORDERS

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Greater trochanteric pain syndrome is a well known clinical entity. The mainstay of treatment is non-operative and includes rest, stretching, physiotherapy and anti-

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inflammatory medications. Steroid injections can alleviate pain and discomfort. Symptoms are however known to recur and can persist especially in patients with underlying pathology. Hip arthroscopy has generated renewed interest in Peri-trochanteric space disorders. Historically, bursal excision, fascial lengthening, Gluteal tendon repair and

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trochanteric osteotomy have been used as open surgical options for recurrent bursitis 33-35. Arthroscopy can effectively treat recalcitrant trochanteric bursitis with a quicker recovery. Bursectomy and decompression along with arthroscopic Iliotibial band release has been

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reported with success36, 37, and 38. Tears of the Gluteus Medius tendon can also mimic trochanteric bursitis and Gluteal complex of the hip has often been compared with rotator

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cuff of the shoulder 38. Recently arthroscopic repair of under-surface tears of the gluteus medius tendon has been reported with success 39, 40. Hip Arthroscopy has also found a clear indication in the management of snapping hip syndromes, both external snapping hip and internal snapping hip. The external snapping hip is produced by the iliotibial band snapping over the prominence of the greater trochanter during flexion and extension. Indication for surgical treatment is painful snapping with

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failure of conservative treatment. The arthroscopic technique releases the iliotibial band producing a defect which allows the greater trochanter to move freely without snapping. The greater trochanteric bursa can be resected simultaneously. There is limited literature regarding the results of arthroscopic treatment for the external snapping hip syndrome, but

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early reports are encouraging41. The internal snapping hip syndrome is produced by the Iliopsoas tendon snapping over the iliopectineal eminence or the femoral head. The

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snapping phenomenon usually occurs with extension of the hip from a flexed position of more than 90 degree. The results of recently reported arthroscopic release of the Iliopsoas

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tendon in the treatment of internal snapping hip syndrome are encouraging and better than open procedures42.

3. PEDIATRIC AND YOUNG ADULT HIP DISORDERS.

Hip arthroscopy can also be performed in a variety of paediatric hip disorders. Current

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indications for hip arthroscopy in pediatric patients include septic arthritis, labral disorders, slipped capital femoral epiphysis, and Legg-Calvé-Perthes disease. Septic arthritis of the hip

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is traditionally treated by open surgical washout. Recently, a comparison of open versus arthroscopic debridement in the paediatric age group has been reported in early septic

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arthritis of the hips in 20 patients43. There is little indication for hip arthroscopy in children with active Legg-Calve-Perthes-Disease (LCPD). Adolescents and young adults however, may present with signs and symptoms as sequelae of LCPD and they can benefit from arthroscopic debridement44,

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. Arthroscopy and osteoplasty may also be beneficial in

patients with previously stabilised slipped capital femoral epiphysis and presenting with mechanical symptoms and signs of impingement46.

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Hip arthroscopy is valuable for direct assessment of the extent and pattern of chondral damage in hip dysplasia. The status of the articular cartilage is a key prognostic indicator in these cases and arthroscopy has a vital role in making decisions for salvage or reconstructive procedures in young adults with hip dysplasia47, 48. Furthermore, associated labral pathology

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can be addressed to help alleviate symptoms, buy time and plan for major and/or definitive surgical treatment49.

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Hip arthroscopy is likely to be more challenging in the paediatric population because of altered anatomy as a result of underlying disorder and any previous surgical treatment. The

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role of hip arthroscopy in the paediatric population will however, continue to expand as a less invasive option for evaluating the hip. 4. TRAUMA AND INFECTION

Patients with persistent symptoms despite congruous reduction after traumatic hip

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dislocation can have improved outcomes with hip arthroscopy. Hip dislocation can be associated with chondral damage, labral tears, loose bodies and ligamentum teres avulsion

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as well as peri-articular fractures. Arthroscopy is usually recommended 3-6 weeks post injury to avoid complications of fluid extravasations and has been reported to be effective in

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these patients50, 51.

The use of arthroscopy in knee sepsis is well established. Arthroscopic lavage and debridement is an attractive minimally invasive option for the treatment of septic hip. Several small series in adult septic hip have been reported with successful outcomes52, 53. Arthroscopic treatment was noticed to have a quicker recovery and shorter hospital stay with no other difference in outcome at 12 months follow up. 5. CHONDRAL INJURIES AND OTHERS.

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ACCEPTED MANUSCRIPT Chondral injuries either alone or in combination with labral pathology can occur with sporting injuries. Debridement alone, microfracture of the exposed bone, or chondrogenic procedures can be carried out with successful outcomes54, 55. Successful arthroscopic cartilage repair has also been reported56, 57. Autologous chondrocyte implantation

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techniques have also been carried out in the hip with successful outcomes58. More recently attention has turned to autologous matrix induced chondrogenesis and results of this are

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awaited with interest.

Synovial hip conditions are being also diagnosed and treated arthoscopically, and there are

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reports of successful foreign body removal by hip arthroscopy and it remains an attractive option for these problems in experienced hands59,60. COMPLICATIONS:

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The complications of hip arthroscopy are mostly related to hip distraction and portal placement during the procedure. In two prospective studies with 640 and 1054 patients, the rate of complications was 1.6% and 1.4% respectively. Most complications were minor and

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only one major complication was reported. Septic arthritis, neuropraxia, haemorrhage, bursitis, instrument breakage, chondral and labral damage and fluid extravasations were

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among them61,62.

Pressure necrosis from the perineal post can be avoided by adequate padding, and by lateralizing the distraction device. Avascular necrosis and femoral neck fracture are considered theoretical complications in excision of an impingement lesion, but have been reported in the literature63. The risk of femoral neck fracture is low if less than 30% of overall diameter of femoral neck has been resected. The recommended area of resection is

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retinacular vessels which are the major blood supply to the femoral head, and run along the lateral femoral neck, as they are susceptible to intra-operative damage65.

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SUMMARY: With Hip arthroplasty being the focus of orthopedic surgeons for decades, Hip arthroscopy has generated a renewed interest for non arthroplasty and minimally invasive

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options for patients with hip pathology especially at a younger age. The procedure is

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minimally invasive and is proving effective for a variety of intra-articular and extra-articular hip problems. The long term outcome of these applications is still awaited. Contrary to knee and other arthroscopy procedures, hip arthroscopy is technically more challenging because of the shape of the joint and the potential dangers of traction. The learning curve is steep

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and the indications are evolving. Nevertheless, it is proving a valuable tool and may well be indispensible for the next generation of hip surgeons.

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Hip Arthroscopy

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Femoro-acetabular Impingement

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Trochanteric pain syndrome

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Highlights