Advanced arthroscopic techniques expand applications
Arthroscopy's minimally invasive approach is now being offered to patients with a wider range of hip disorders. This development requires the mastery of advanced arthroscopic techniques to fully leverage the more effective instrumentation now available, as well as the enhanced recognition of hip anatomy.
Elements of success
Innovative applications are typically seen at high-volume specialty orthopedic centers staffed to accommodate the steep learning curve of advanced arthroscopy. According to Mayo Clinic orthopedic surgeons, hip arthroscopy can be especially technically demanding. One key to success is development of a supportive infrastructure of surgical expertise that can rapidly adapt to new arthroscopic applications as the technology becomes available.
For the best outcomes with advanced arthroscopic techniques in the hip, Mayo Clinic specialists note the importance of having dedicated orthopedic aftercare and rehabilitation specialists who are integral members of the team. Expanding applications of hip arthroscopy can also be attributed to improved understanding of the specific pathoanatomy of the hip. When combined with technical advances in surgical instrumentation, this understanding enables more areas in and around the hip to be accessed through arthroscopic surgery. One such area is the peritrochanteric space, the area outside the hip joint where the powerful abductor muscles are located, including the gluteus medius and minimus and the associated trochanteric bursa.
Gluteus medius repair
The gluteus medius is the main abductor muscle in the hip that allows a person to walk with a level pelvis. Some patients with lateral hip pain and weakness may have a gluteus medius tear. This tendon can be accessed arthroscopically in the peritrochanteric space of the hip and can be thought of as very similar to the rotator cuff of the shoulder.
Internal snapping hip syndrome
In patients with internal snapping hip syndrome, a painful sensation is caused by slippage of the iliopsoas tendon as it crosses the anterior femoral head or the iliopectineal eminence. It typically occurs as the hip comes from the flexed, abducted, externally rotated position toward extension. Pain emanates from the groin and can be confused with hip joint pathology.
With advanced arthroscopic techniques, the surgeon can pass through the central compartment of the hip during arthroscopy, making a small window in the capsule to locate the tendon and release it. At this level it's approximately 50 percent muscle and 50 percent tendon, so it's more like a fractional lengthening of the muscle as opposed to a complete detachment.
Treatment of the capsule
Among the most recent advances in arthroscopic hip surgery is the treatment of the capsule. In the past, to access the hip joint the surgeon would cut through the capsule and often remove significant amounts of capsule. This approach may have contributed to instability of the hip in the form of microinstabilities.
Now, with newer techniques and instrumentation, arthroscopic surgeons usually can restore the anatomy by closing the capsule that has been cut. This approach minimizes the amount of capsule resected and helps stabilize the hip.
Recently it has been recognized that there is a pathological relationship between femoro-acetabular impingement (FAI) and the development of early osteoarthritis of the hip joint in young adults.
This patient group has an underlying structural deformity in one or both of the two parts of the hip joint, the femoral head and neck or the acetabulum. These deformities give rise to distinctive types of lesions: Pincer rim lesions amount to an over-coverage of the femoral head by the acetabular rim. Cam lesions create a bony protuberance that forms at the junction of the femoral head and neck.
Patients typically seek medical care due to pain from a labral tear. In the past, all FAI patients were treated with an open surgical hip dislocation to gain access. Labral tears were repaired with sutures and anchors, and the normal geometry of the hip joint and sphericity of the femoral head-neck junction were restored surgically.
These same repairs can now be made in carefully selected patients using advanced arthroscopic technique and improved instrumentation. Experience among Mayo Clinic orthopedic surgeons and reports in the literature show that arthroscopic FAI patients tend to have less morbidity, significantly less pain and less challenging rehabilitation due to the minimally invasive nature of the procedure.
Clinical trials test open vs. arthroscopic management of FAI
To further improve the evidence base of FAI management, Mayo Clinic orthopedic surgeons are developing two randomized clinical trials. One evaluates open surgery vs. arthroscopic management of FAI, and the other addresses perioperative pain management with nerve blocks vs. absence of nerve blocks.
Points to remember
- Patients with a wide range of hip disorders, including gluteus medius tears, internal snapping hip syndrome and femoroacetabular impingement (FAI) can benefit from hip arthroscopy.
- Because hip arthroscopy is technically demanding, the best surgical outcomes are obtained at high-volume specialty orthopedic centers that have experienced surgeons and dedicated orthopedic aftercare and rehabilitation specialists who are integral members of the team.