Hip
Hip arthroscopy is a recent technique, developing rapidly over the past fifteen years, allowing for the repair of the joint when it is not yet too damaged. Thus, it is part of the treatments that preserve the native hip.
Indeed, we are increasingly realizing that at least 40% of hip osteoarthritis could be due to untreated old lesions or small anatomical defects leading to the slow and progressive destruction of the joint.
Hip-preserving surgery, notably arthroscopy, allows for the repair of these lesions and anatomical defects in patients before the joint damage becomes irreversible and hip replacement becomes the only remaining solution.
Arthroscopy involves the insertion of a camera and thin instruments into the joint to perform a surgical intervention without tissue destruction. There is no muscle cutting, and the scars are pinpoint.
This process, therefore, allows for a quicker recovery, which is why arthroscopies are most often performed on an outpatient basis.
What pathologies can be treated with hip arthroscopy?
1) Femoroacetabular Impingement (FAI):
This is a dynamic pathology, characterized by the abnormal contact of the femoral neck against the rim of the acetabulum during hip flexion and rotation. The labrum and the cartilage on this rim are repeatedly crushed, leading to their fissuring.
This contact can originate either from the presence of a bone bump on the femoral neck (cam effect), or from a too prominent acetabular rim (pincer or clamp effect). The combination of both deformities is common, referred to as a mixed impingement.
Certain sports requiring large ranges of motion are particularly prone to impingements, such as combat sports, classical dance, ballet, etc. Some professions are also predisposed, especially those requiring squatting on the ground (e.g., tilers, mechanics), or extreme prolonged or repetitive hip flexion (e.g., taxi drivers).
The procedure involves shaving the bone areas causing the impingement, at the level of the femur and/or the acetabulum, using a motorized arthroscopic burr. It is often also necessary to repair sequela lesions of the impingement, such as tears of the labrum or cartilage.
2) Labral lesions
The labrum is an elastic joint attached to the periphery of the acetabulum, which ensures the tightness and stability of the hip. It has the same consistency as a meniscus in the knee, somewhat like soft rubber.
Its lesion is sometimes isolated but most often secondary to other pathologies, such as femoroacetabular impingement or hip instability. This lesion is often the cause of pain.
During an arthroscopy, the main objective is to save the labrum by performing a suture: Harpoons inserted into the bone (anchors) allow it to be reattached to the rim of the acetabulum.
Parts of the labrum that are too frayed and not amenable to suturing are debrided, trying to preserve as much labral tissue as possible.
3) Cartilage lesions
Like labral lesions, they are most often secondary to femoroacetabular impingement or hip instability. When these lesions are in their early stages, they can benefit from treatment under arthroscopy.
The possible technical procedures vary according to the indications: bone microfracture, cartilage grafting, mosaicplasty, etc.
4) Synovial pathologies
The synovial membrane lines the inner surface of all joints. It produces a lubricating fluid called synovial fluid and plays a significant biochemical and immunological role.
Certain synovial pathologies can lead to the destruction of the hip cartilage.
The most common are synovial chondromatosis (formation of cartilage "flakes" in the joint cavity) and pigmented villonodular synovitis (thickening of the synovial membrane in the form of villi and nodules). These are benign tumor pathologies in both cases, but the accompanying inflammation can be very painful and resistant to non-surgical treatment, hence the need for intervention.
Arthroscopy allows for visual diagnostic confirmation and intra-articular biopsies, as well as treatment by debridement (partial or complete depending on the pathology) of the synovial membrane.
It also allows for the removal of cartilage "flakes" from the joint cavity.
5) Hip tendinitis and tendinopathy
It's the inflammation of one or more tendons around the hip that causes your pain and discomfort. It can be a simple inflammation, or more significant lesions such as a tear or rupture of the tendon. This is then referred to as tendinopathy.
Most often, it involves the tendons of the gluteus medius, gluteus minimus, or iliopsoas.
As with the rotator cuff in the shoulder, debridement with repair of the damaged tendon can be performed either openly or by arthroscopy, depending on the type, extent, and location of the lesion. Anchors can be used if necessary to reattach the tendon to its bony insertion.
6) Hip microinstability
It involves excessive laxity of your joint, or a shallow acetabulum, leading to insufficient coverage of the femoral head, which can result in lesions of the labrum and/or cartilage.
The treatment addresses the articular capsule, which contains the ligaments stabilizing the hip and can be tightened. This procedure is known as capsular plication.
In severe cases where there is a significant coverage defect of the femoral head in a very young patient, a hip impingement surgery can be performed. This involves grafting a small bone block onto the roof of the acetabulum to increase its coverage.
Is there an alternative to surgery?
In most cases, the medical treatment of hip pain is a mandatory step.
We have a multitude of “small means” to try to control the symptoms without surgery: Avoiding traumatic movements or extreme positions, injections, PRP injections, anti-inflammatories, and painkillers, etc.
Well-conducted physical therapy can be of decisive utility: through specific work to correct certain movements, and by primarily strengthening the muscle groups that separate the bones in conflict, it can improve symptoms and avoid surgery.
If the well-followed medical treatment proves insufficient and the impact of symptoms on your physical and sports activities is significant, performing a hip arthroscopy becomes necessary.
Your surgery:
In the month preceding the surgery, you will have a consultation with the anesthetist, who will analyze all your medical data and will propose the type of anesthesia accordingly: general anesthesia (you are completely asleep throughout the surgery) or spinal anesthesia (injection in the back similar to an epidural, only the lower body is anesthetized). You will be able to share your preferences. Each anesthesia method has its advantages. If you do not want to see, hear, or feel anything, general anesthesia is ideal for you.
If you are apprehensive about falling asleep and prefer to keep a sense of “control” over the situation, you can request spinal anesthesia. Hip arthroscopy cannot be performed under pure local anesthesia.
During the surgery, you are laid on your back on a special table, called an orthopedic table. It allows us to position and hold the legs and therefore the hip. Hip arthroscopy is most often performed under radiological control using a mobile radiographic arch.
In most cases, the surgery is carried out on an outpatient basis. I will come to see you in your room at the end of the day before your discharge and will give you post-operative instructions, as well as prescriptions (dressings, painkillers, physiotherapy, etc.). You will probably have to walk with crutches for a few weeks, with or without bearing weight on the operated side, depending on your case. A daily injection of anticoagulant is necessary to avoid the risk of thrombosis. In some cases, a high-dose anti-inflammatory treatment is prescribed for a short period to prevent the formation of post-operative tissue calcifications.
We will meet regularly for follow-up consultations, and we will plan together the stages of rehabilitation, as well as the gradual resumption of regular activities, especially sports, work, and driving.
The final result of the surgery can only be evaluated after 6 months and sometimes up to 1 to 2 years. Do not forget that your joint has been ill for several months, if not years. Your muscles have weakened in parallel. With regular and well-measured efforts, without going too fast or too strong, you will experience constant progress, sometimes punctuated by small setbacks that should not worry or discourage you!
