- Email: [email protected]
Hip arthroscopy: Minimally invasive surgery for hip pathologies
MJAFI-781; No. of Pages 4 medical journal armed forces india xxx (2016) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/mjafi
Short Communication
Hip arthroscopy: Minimally invasive surgery for hip pathologies Lt Col Munish Sood a,*, Col Amresh Ghai b a b
Classified Specialist (Orthopaedics), Command Hospital (Western Command), Chandimandir 134107, India Classified Specialist & Head of Department (Orthopaedics), Base Hospital, Delhi Cantt 110010, India
article info
abstract
Article history:
Arthroscopy is considered as one of the revolutionary techniques in the management of
Received 23 April 2016
musculoskeletal disorders. Hip arthroscopy is a new emerging technique for the manage-
Accepted 8 September 2016
ment of hip pathologies and it has gained popularity in the past decade. In the present case
Available online xxx
series, 5 patients with hip pathologies were operated using hip arthroscopy technique and the functional outcome and complications associated with hip arthroscopy were assessed.
Keywords:
Harris hip score improved significantly at the latest follow-up. No major complication was
Hip joint
noticed in our case series. In conclusion, hip arthroscopy procedure requires good instru-
Arthroscopic surgery
mentation and expertise. We believe that it is a safe and less invasive procedure providing an
Portals
additional tool in the management of hip pathologies.
Complications
# 2016 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Introduction Arthroscopic surgery is considered as one of the most minimally invasive surgical procedures. It is regarded as one of the major breakthroughs in the management of patients with conditions affecting the musculoskeletal system. Hip arthroscopic surgery was introduced for the first time by Burman in 1931.1 However, indications and procedures for arthroscopic surgeries remained very few for many decades because of lack of expertise and instrumentation. Since the early 1990s, the number of hip arthroscopic surgeries being performed has increased worldwide. Hip arthroscopy was introduced in India in the past decade only and still there are very few centres in India that perform arthroscopic management of hip pathologies. Ours is one of the very few centres in
the armed forces where these kinds of surgeries have been performed in the past five years. We present here a case series of 5 patients who were managed with hip arthroscopy at our centre.
Material and method A prospective study was carried out from 01 January 2014 to 30 December 2015 in a tertiary care orthopaedics centre. A total of five patients who were having hip pathology and were being managed using hip arthroscopy were included in this study. The average age of the patients was 38.5 years. All patients were male. All the patients who presented with hip pain were initially evaluated at our centre for hip pathology. The clinical features included hip pain, limp, painful ambulation, clicking
* Corresponding author. E-mail address: [email protected] (M. Sood). http://dx.doi.org/10.1016/j.mjafi.2016.09.005 0377-1237/# 2016 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
2
medical journal armed forces india xxx (2016) xxx–xxx
Table 1 – Indications for which hip arthroscopy was performed. Synovial chondromatosis and loose bodies removal Femoro-acetabular impingement Synovial biopsy
Fig. 1 – Plain radiograph revealing radiopaque lesion in the acetabular fossa in the left hip joint.
or locking sensation on rotation of the hip. All the patients were examined in supine and standing position and pain on rotation of hip was elicited. Patients were further evaluated radiologically with radiograph of hip and pelvis, computed tomography (CT) scan or magnetic resonance imaging (Figs. 1 and 2). The various indications for which hip arthroscopy was performed are listed in Table 1.
Hip arthroscopic procedure Hip arthroscopy was performed under spinal anaesthesia and patients were placed in the supine position. The patient was placed on a fracture table and traction using padded foot and boot was applied to the operative leg. The hip joint was distracted to increase the joint space by 1–2 cm. The standard
03 01 01
lateral, anterior and accessory anterior portals were made in all the cases under C-arm image intensifier (Figs. 3 and 4). In two patients, posterolateral portal was made for better visualisation and removal of loose bodies from the hip joint. All the important landmarks including the bony landmark and neurovascular bundle were identified by palpation and marked to reduce the possibility of damage to the neurovascular and other important structures. Hip joint and various pathologies were assessed using the arthroscope; a 708 arthroscope was mainly used in the lateral portal while the instruments such as the probe, grasper, shaver and electrothermal device were inserted via the anterior portal. The operative time, functional outcome and postoperative complication were assessed.
Results A total of 5 patients (Table 2) with hip pathology were operated using hip arthroscopy technique at this tertiary orthopaedics centre. All patients were male with average age of 38.5 years (range, 27–51 years). Patients were followed-up for an average period of 16.8 months (range, 08–24 months). The average surgical time was 80 min (range, 40–190 min). Totally, three portals were used during all surgeries (anterior, accessory anterior and lateral), and in two cases, posterolateral portal was also made. In patients with synovial chondromatosis, removal of intra-articular loose bodies and partial synovectomy was done (Fig. 5), whereas in the patient with femoroacetabular impingement, resection of the prominent portion of head–neck junction of femur was done. In one patient, biopsy was carried out; he was diagnosed as a case of
Fig. 2 – MRI and CT scan shows clusters of intra-articular ossified loose bodies filling the hip joint. Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
3
medical journal armed forces india xxx (2016) xxx–xxx
Fig. 3 – Position of various portals under C-arm image intensifier.
Fig. 5 – Loose bodies removed from hip joint.
short follow-up, there was no evidence of the development of any post-traumatic osteoarthritis in any case in our series.
Discussion
Fig. 4 – Loose bodies observed in the acetabular fossa.
tuberculosis and the patient improved after the course of antituberculosis treatment. Patients were functionally assessed using Harris hip score,2 which improved from an average of 57.8 preoperatively to 82.3 at the last follow-up. In one of the patient, there was mild trauma to femoral head due to arthroscope. However, no major complication was noticed in portal placement during the surgery or postoperatively. In a
Although hip arthroscopy came into existence in 1930, indications for this procedure were very few till 1990s. With greater awareness about new pathologies like labrum tear, chondral injuries and femoro-acetabular impingement and advancement in technology, the use of hip arthroscopy as an alternative to the open procedure has increased worldwide.3–5 The main indications for which hip arthroscopy procedures are performed include loose bodies removal in chondromatosis, femoro-acetabular impingement, management of labrum tear, arthroscopic debridement in septic arthritis, ligamentum teres ruptures, snapping hip syndrome, management of early osteoarthritis and pathologies in acetabular dysplasia, while the contraindications for these procedures are ankylosed hip, superficial infection of skin or tissue and very obese patient.6–13 The advantages of hip arthroscopic procedure are minimally invasiveness, minimal injury to soft tissue with lesser blood loss and lesser rehabilitation period as compared to the open procedure. It does not have disadvantages of the open procedure, which sometimes require dislocation of the hip
Table 2 – Case series. Patient 1 2 3 4 5
Age (years)
Diagnosis
Surgery
Complication
34 27 51 31 48
Synovial chondromatosis Femoro-acetabular impingement Synovial chondromatosis Synovial chondromatosis Synovitis hip
Removal of loose bodies and synovectomy Resection of prominent head–neck junction Removal of loose bodies and synovectomy Removal of loose bodies and synovectomy Biopsy
Nil Nil Trauma to head femur Nil Nil
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
4
medical journal armed forces india xxx (2016) xxx–xxx
joint, and increases the chances of avascular necrosis of the femoral head, fracture of the femoral neck and nerve injuries.14 Complications of this procedure include transient complications like neuropraxia secondary to traction, excessive bleeding from the portal site, bursitis mainly trochanteric and serious complications like neurovascular injuries. In our series of five patients, good functional outcome was achieved in all the patients. One patient has minimal trauma to the head of the femur because of the iatrogenic injury during trocar insertion but there was no injury to labrum or any other complication. One of the main drawbacks of the study was the short follow-up. The hip arthroscopic procedure has a long learning curve, requiring specially designed instrumentations. There are recent reports suggesting improved clinical outcome and lesser complications with improvement in technology and as one gains experience in hip arthroscopic technique.15,16 In conclusion, hip arthroscopy has the following advantages over a traditional hip arthrotomy: (1) It does not require dislocation of the hip, which lessens serious complications such as avascular necrosis of the femoral head. (2) Under the arthroscopic magnification, good visualisation of pathology can be done properly with arthroscopic instruments. (3) Hip arthroscopy because of a short rehabilitation period allows early return to functional status after the surgery.
Conflicts of interest The authors have none to declare.
references
2. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. J Bone Joint Surg Am. 1969;51:737–755. 3. Byrd JT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy. 2004;20(4):385–391. 4. Krebs VE. The role of hip arthroscopy in the treatment of synovial disorders and loose bodies. Clin Orthop Relat Res. 2003;406(1):48–59. 5. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88–92. 6. Christensen CMJ, Mittleman M. Outcomes. In: McCarthy J, ed. In: Early Hip Disorders. New York: Springer; 2003:195–200. 7. Rath E, Tsvieli O, Levy O. Hip arthroscopy: an emerging technique and indications. Isr Med Assoc J. 2012;14(3): 170–174. 8. Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy. 2003;19(10):1055–1060. 9. McCarthy J, Barsoum W, Puri L, Lee JA, Murphy S, Cooke P. The role of hip arthroscopy in the elite athlete. Clin Orthop Relat Res. 2003;406(1):71–74. 10. Kim SJ, Choi NH, Ko SH, Linton JA, Park HW. Arthroscopic treatment of septic arthritis of the hip. Clin Orthop Relat Res. 2003;407(1):211–214. 11. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery. Current concepts and perspective. Bone Joint J. 2013;95(1):10–19. 12. Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy. 2011;27(2):172–181. 13. Byrd JW, Jones KS. Osteoarthritis caused by an inverted acetabular labrum: radiographic diagnosis and arthroscopic treatment. Arthroscopy. 2002;18(7):741–747. 14. Knoeller SM. Synovial osteochondromatosis of the hip joint. Etiology, diagnostic investigation and therapy. Acta Orthop Belgica. 2001;67:201–210. 15. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406:84–88. 16. Sampson TG. Complications of hip arthroscopy. Techn Orthop. 2005;20(1):63–66.
1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg Am. 1931;13(4):669–695.
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/mjafi
Short Communication
Hip arthroscopy: Minimally invasive surgery for hip pathologies Lt Col Munish Sood a,*, Col Amresh Ghai b a b
Classified Specialist (Orthopaedics), Command Hospital (Western Command), Chandimandir 134107, India Classified Specialist & Head of Department (Orthopaedics), Base Hospital, Delhi Cantt 110010, India
article info
abstract
Article history:
Arthroscopy is considered as one of the revolutionary techniques in the management of
Received 23 April 2016
musculoskeletal disorders. Hip arthroscopy is a new emerging technique for the manage-
Accepted 8 September 2016
ment of hip pathologies and it has gained popularity in the past decade. In the present case
Available online xxx
series, 5 patients with hip pathologies were operated using hip arthroscopy technique and the functional outcome and complications associated with hip arthroscopy were assessed.
Keywords:
Harris hip score improved significantly at the latest follow-up. No major complication was
Hip joint
noticed in our case series. In conclusion, hip arthroscopy procedure requires good instru-
Arthroscopic surgery
mentation and expertise. We believe that it is a safe and less invasive procedure providing an
Portals
additional tool in the management of hip pathologies.
Complications
# 2016 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Introduction Arthroscopic surgery is considered as one of the most minimally invasive surgical procedures. It is regarded as one of the major breakthroughs in the management of patients with conditions affecting the musculoskeletal system. Hip arthroscopic surgery was introduced for the first time by Burman in 1931.1 However, indications and procedures for arthroscopic surgeries remained very few for many decades because of lack of expertise and instrumentation. Since the early 1990s, the number of hip arthroscopic surgeries being performed has increased worldwide. Hip arthroscopy was introduced in India in the past decade only and still there are very few centres in India that perform arthroscopic management of hip pathologies. Ours is one of the very few centres in
the armed forces where these kinds of surgeries have been performed in the past five years. We present here a case series of 5 patients who were managed with hip arthroscopy at our centre.
Material and method A prospective study was carried out from 01 January 2014 to 30 December 2015 in a tertiary care orthopaedics centre. A total of five patients who were having hip pathology and were being managed using hip arthroscopy were included in this study. The average age of the patients was 38.5 years. All patients were male. All the patients who presented with hip pain were initially evaluated at our centre for hip pathology. The clinical features included hip pain, limp, painful ambulation, clicking
* Corresponding author. E-mail address: [email protected] (M. Sood). http://dx.doi.org/10.1016/j.mjafi.2016.09.005 0377-1237/# 2016 Published by Elsevier B.V. on behalf of Director General, Armed Forces Medical Services.
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
2
medical journal armed forces india xxx (2016) xxx–xxx
Table 1 – Indications for which hip arthroscopy was performed. Synovial chondromatosis and loose bodies removal Femoro-acetabular impingement Synovial biopsy
Fig. 1 – Plain radiograph revealing radiopaque lesion in the acetabular fossa in the left hip joint.
or locking sensation on rotation of the hip. All the patients were examined in supine and standing position and pain on rotation of hip was elicited. Patients were further evaluated radiologically with radiograph of hip and pelvis, computed tomography (CT) scan or magnetic resonance imaging (Figs. 1 and 2). The various indications for which hip arthroscopy was performed are listed in Table 1.
Hip arthroscopic procedure Hip arthroscopy was performed under spinal anaesthesia and patients were placed in the supine position. The patient was placed on a fracture table and traction using padded foot and boot was applied to the operative leg. The hip joint was distracted to increase the joint space by 1–2 cm. The standard
03 01 01
lateral, anterior and accessory anterior portals were made in all the cases under C-arm image intensifier (Figs. 3 and 4). In two patients, posterolateral portal was made for better visualisation and removal of loose bodies from the hip joint. All the important landmarks including the bony landmark and neurovascular bundle were identified by palpation and marked to reduce the possibility of damage to the neurovascular and other important structures. Hip joint and various pathologies were assessed using the arthroscope; a 708 arthroscope was mainly used in the lateral portal while the instruments such as the probe, grasper, shaver and electrothermal device were inserted via the anterior portal. The operative time, functional outcome and postoperative complication were assessed.
Results A total of 5 patients (Table 2) with hip pathology were operated using hip arthroscopy technique at this tertiary orthopaedics centre. All patients were male with average age of 38.5 years (range, 27–51 years). Patients were followed-up for an average period of 16.8 months (range, 08–24 months). The average surgical time was 80 min (range, 40–190 min). Totally, three portals were used during all surgeries (anterior, accessory anterior and lateral), and in two cases, posterolateral portal was also made. In patients with synovial chondromatosis, removal of intra-articular loose bodies and partial synovectomy was done (Fig. 5), whereas in the patient with femoroacetabular impingement, resection of the prominent portion of head–neck junction of femur was done. In one patient, biopsy was carried out; he was diagnosed as a case of
Fig. 2 – MRI and CT scan shows clusters of intra-articular ossified loose bodies filling the hip joint. Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
3
medical journal armed forces india xxx (2016) xxx–xxx
Fig. 3 – Position of various portals under C-arm image intensifier.
Fig. 5 – Loose bodies removed from hip joint.
short follow-up, there was no evidence of the development of any post-traumatic osteoarthritis in any case in our series.
Discussion
Fig. 4 – Loose bodies observed in the acetabular fossa.
tuberculosis and the patient improved after the course of antituberculosis treatment. Patients were functionally assessed using Harris hip score,2 which improved from an average of 57.8 preoperatively to 82.3 at the last follow-up. In one of the patient, there was mild trauma to femoral head due to arthroscope. However, no major complication was noticed in portal placement during the surgery or postoperatively. In a
Although hip arthroscopy came into existence in 1930, indications for this procedure were very few till 1990s. With greater awareness about new pathologies like labrum tear, chondral injuries and femoro-acetabular impingement and advancement in technology, the use of hip arthroscopy as an alternative to the open procedure has increased worldwide.3–5 The main indications for which hip arthroscopy procedures are performed include loose bodies removal in chondromatosis, femoro-acetabular impingement, management of labrum tear, arthroscopic debridement in septic arthritis, ligamentum teres ruptures, snapping hip syndrome, management of early osteoarthritis and pathologies in acetabular dysplasia, while the contraindications for these procedures are ankylosed hip, superficial infection of skin or tissue and very obese patient.6–13 The advantages of hip arthroscopic procedure are minimally invasiveness, minimal injury to soft tissue with lesser blood loss and lesser rehabilitation period as compared to the open procedure. It does not have disadvantages of the open procedure, which sometimes require dislocation of the hip
Table 2 – Case series. Patient 1 2 3 4 5
Age (years)
Diagnosis
Surgery
Complication
34 27 51 31 48
Synovial chondromatosis Femoro-acetabular impingement Synovial chondromatosis Synovial chondromatosis Synovitis hip
Removal of loose bodies and synovectomy Resection of prominent head–neck junction Removal of loose bodies and synovectomy Removal of loose bodies and synovectomy Biopsy
Nil Nil Trauma to head femur Nil Nil
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005
MJAFI-781; No. of Pages 4
4
medical journal armed forces india xxx (2016) xxx–xxx
joint, and increases the chances of avascular necrosis of the femoral head, fracture of the femoral neck and nerve injuries.14 Complications of this procedure include transient complications like neuropraxia secondary to traction, excessive bleeding from the portal site, bursitis mainly trochanteric and serious complications like neurovascular injuries. In our series of five patients, good functional outcome was achieved in all the patients. One patient has minimal trauma to the head of the femur because of the iatrogenic injury during trocar insertion but there was no injury to labrum or any other complication. One of the main drawbacks of the study was the short follow-up. The hip arthroscopic procedure has a long learning curve, requiring specially designed instrumentations. There are recent reports suggesting improved clinical outcome and lesser complications with improvement in technology and as one gains experience in hip arthroscopic technique.15,16 In conclusion, hip arthroscopy has the following advantages over a traditional hip arthrotomy: (1) It does not require dislocation of the hip, which lessens serious complications such as avascular necrosis of the femoral head. (2) Under the arthroscopic magnification, good visualisation of pathology can be done properly with arthroscopic instruments. (3) Hip arthroscopy because of a short rehabilitation period allows early return to functional status after the surgery.
Conflicts of interest The authors have none to declare.
references
2. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. J Bone Joint Surg Am. 1969;51:737–755. 3. Byrd JT, Jones KS. Traumatic rupture of the ligamentum teres as a source of hip pain. Arthroscopy. 2004;20(4):385–391. 4. Krebs VE. The role of hip arthroscopy in the treatment of synovial disorders and loose bodies. Clin Orthop Relat Res. 2003;406(1):48–59. 5. Robertson WJ, Kadrmas WR, Kelly BT. Arthroscopic management of labral tears in the hip: a systematic review of the literature. Clin Orthop Relat Res. 2007;455:88–92. 6. Christensen CMJ, Mittleman M. Outcomes. In: McCarthy J, ed. In: Early Hip Disorders. New York: Springer; 2003:195–200. 7. Rath E, Tsvieli O, Levy O. Hip arthroscopy: an emerging technique and indications. Isr Med Assoc J. 2012;14(3): 170–174. 8. Byrd JW, Jones KS. Hip arthroscopy in the presence of dysplasia. Arthroscopy. 2003;19(10):1055–1060. 9. McCarthy J, Barsoum W, Puri L, Lee JA, Murphy S, Cooke P. The role of hip arthroscopy in the elite athlete. Clin Orthop Relat Res. 2003;406(1):71–74. 10. Kim SJ, Choi NH, Ko SH, Linton JA, Park HW. Arthroscopic treatment of septic arthritis of the hip. Clin Orthop Relat Res. 2003;407(1):211–214. 11. Bedi A, Kelly BT, Khanduja V. Arthroscopic hip preservation surgery. Current concepts and perspective. Bone Joint J. 2013;95(1):10–19. 12. Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy. 2011;27(2):172–181. 13. Byrd JW, Jones KS. Osteoarthritis caused by an inverted acetabular labrum: radiographic diagnosis and arthroscopic treatment. Arthroscopy. 2002;18(7):741–747. 14. Knoeller SM. Synovial osteochondromatosis of the hip joint. Etiology, diagnostic investigation and therapy. Acta Orthop Belgica. 2001;67:201–210. 15. Clarke MT, Arora A, Villar RN. Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406:84–88. 16. Sampson TG. Complications of hip arthroscopy. Techn Orthop. 2005;20(1):63–66.
1. Burman MS. Arthroscopy or the direct visualization of joints. J Bone Joint Surg Am. 1931;13(4):669–695.
Please cite this article in press as: Sood M, Ghai A. Hip arthroscopy: Minimally invasive surgery for hip pathologies, Med J Armed Forces India. (2016), http://dx.doi.org/10.1016/j.mjafi.2016.09.005