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Introduction | The Operation | Recovery

Hip Arthroscopy

Arthroscopy, also popularly known as keyhole surgery, is a procedure in which a small camera is introduced through a small incision (keyhole) to examine inside of your joint. In hip arthroscopy a small camera called arthroscope is inserted into the hip joint through a small keyhole. It gives a clear view of the inside of the hip joint and allows the surgeons to diagnose and treat some conditions of the hip joint.

Mr Samsani has been performing these hip arthroscopies to treat various conditions of the hip joint as a Consultant Hip and Knee Surgeon at Medway NHS Foundation Hospital Trust Gillingham, England.

Anatomy of Hip Joint

he hip joint is a large deep seated ball and socket joint. The ball is formed by the upper end of thigh bone (femur) and socket (acetabulum) is formed by a part of the hip bone. The hip joint is held together by a capsule, strong ligaments and muscles around the hip joint. The inner aspect of joint capsule is lined by special tissue called synovial membrane which secretes synovial fluid to lubricate the hip joint.

The joint surface of the ball and socket is covered by a special tissue called articular cartilage which allows smooth painless movement of hip joint without friction. A strong fibro-cartilage called labrum is attached to the periphery of the socket (acetabulum). The labrum helps to provide extra stability to hip joint.

Which conditions are treated with hip arthroscopy?

Hip arthroscopy may be indicated for a wide range of painful hip conditions. A course of non-operative treatment with pain killers, activity modification, physiotherapy or intra-articular hip injections may be tried before considering hip arthroscopy. Various painful hip conditions that can be treated with hip arthroscopy are:

• Hip Impingement: It is a painful hip condition caused by a bony overgrowth either on     the femoral head (ball) or periphery of acetabulum (socket) or sometimes both. It is     usually seen in young people and can cause pain, clicks, locking and stiffness of the     hip joint. It may lead to arthritis of the hip joint if left untreated.
• Articular cartilage defects: Damage to the articular cartilage of the hip can cause pain     and stiffness. If left untreated it may result in arthritis. Cartilage defects can be     cleaned and small drill holes are made in the bone (microfracture) so that a new type     of cartilage can grow and line the hip joint which helps to relieve symptoms.
Labral tears: The labrum at the periphery of the socket provides extra stability to the     hip joint. Labral tears can cause pain, clicks and instability and are usually associated     with impingement or acetabular dysplasia.
• Loose bodies: loose pieces of bone or cartilage can come off from the hip and float     freely in the joint space. These loose bodies can cause pain, locking and instability of     hip. These can be removed during hip arthroscopy.
• Tears of Ligamentum teres: Ligamentum teres is a strong ligament that connects ball     to the socket. This ligament can be torn by an injury to hip joint.
• Dysplasia: Is a condition where the socket is shallow from birth. The acetabular     dysplasia may be associated with labral tears.
• Hip infection: Hip arthroscopy is very useful to clean the hip joint and also to obtain     fluid and tissue sample for cultures so that bacteria can be isolated and effective     antibiotic treatment can be started.
• Undiagnosed hip pain: sometimes hip arthroscopy may be helpful to diagnose the     cause of an undiagnosed hip pain.

What happens before hip arthroscopy?

Clinical Assessment: Mr Samsani will conduct a physical examination including detailed history of your problem, clinical examination of hip and obtain routine x-rays of the hip. To confirm the diagnosis you may also need to have special scans such as MRI and CT scans. After confirming the nature of the problem, Mr Samsani will also discuss with you the various treatment options available to treat the condition including non-operative and operative options. Usually a course of non-operative treatment is considered first and hip arthroscopy is considered when the non-operative treatment has been ineffective.

Tests: Once you have agreed to proceed with the operation, it is important to make sure that you are fit to undergo the operation. As part of a pre-operative assessment, you may have some or all of the following tests depending on your medical condition:

• Blood tests
• Urine tests
• X-ray of knee
• X-ray of chest

You may also require a medical examination by a medical doctor to make sure you are fit for surgery and identify any medical problems that could interfere with your surgery.

Inform Mr Samsani or his team all the medication you take regularly. You may be informed to stop taking certain medication before surgery.

A Physiotherapist will see you and advise you about exercises that will keep the hip in the best possible condition before surgery and help to recover quickly after the operation.

Mr Samsani will also inform you about when to come to the hospital for surgery and also when to stop eating or drinking before the operation.

Hip Arthroscopy operation

You are likely to be admitted on the day of operation. Hip arthroscopy is usually performed as a day case operation but sometimes may require a few days of hospitalisation. The operation usually takes 60 to 90 minutes depending on the findings and the specific treatment required.

A member of the anaesthetic team will see you before the operation and discuss the anaesthetic options. Hip arthroscopy is usually performed under general anaesthesia. Your hip will be identified and marked prior to anaesthetic being administered.

Once you are under anaesthetic, traction is applied to the leg. This traction creates enough space in the hip joint to enable the surgeon to introduce an athroscope and other special instruments to perform the hip arthroscopy. A sterile solution will be used to distend the hip joint and washout the debris.

An arthroscope is introduced through a small incision made on the outside of hip joint and the inside of the hip joint is visualised and the problem is identified. Another small incision is made close to the first incision to introduce special instrument such as shaver, burr, coblater etc. to treat the problem.

Hip arthroscopy is commonly used to treat the following conditions:

• To repair or smoothen off cartilage (labrum) tear.
• To clean and “microfracture” damaged articular cartilage.
• To remove loose bodies (broken bits of cartilage and bone).
• To remove and smoothen bony overgrowth caused by femoroacetabular impingement.
• To remove inflamed synovial tissue (lining of hip joint).
• After completion of the procedure, the small incisions are closed either with a stitch or steri-strips (small sterile tapes). At the end of the procedure a local anaesthetic solution is injected into the hip for pain relief.

After the operation you will be moved to recovery for close monitoring. Once your observations are stable you will then be moved to a ward.

On the ward nurses will look after you. The Physiotherapist will visit you on the ward and teach you exercises and help you use crutches. You should be able to go home when you are comfortable and are able to walk with the help of crutches. Someone should accompany you for about 24 hours after surgery.

Recovery after hip arthroscopy

Recovery after hip arthroscopy is generally quicker than open hip surgery. Most patients go home a few days after the operation.

You may have some discomfort in the hip for few days and pain killers will be prescribed to control the discomfort. You may also be prescribed medication to minimise the risk of blood clots.

A Physiotherapist will see you and demonstrate a number of exercises for you to do at home. These exercises are important to restore the hip movement and strengthen muscles of the leg.

You will need crutches or other walking aides for a while after the operation. Mr Samsani or his team will tell you when you can safely weight bear on your leg.

You can remove the bulky outer dressing in 48 hours leaving the waterproof dressings on the wounds untouched. Mr Samsani’s team will tell you when you can have a bath or shower and when you should change the dressing.

You will be assessed in few weeks after surgery by Mr Samsani to monitor your progress and discuss the operative findings.

Some amount of swelling and bruising of the hip are common after arthroscopy. Elevation of the leg when seated and application of ice packs on the hip helps to reduce swelling and bruising (place ice packs on the hip for 15 minutes 3 to 4 times a day).

Sometimes patients may feel some tingling or numbness in the foot, groin or leg after operation and this will gradually settle with time.

The small incisions on the hip heal in 10 to 14 days time.

It is very important to follow the exercise programme given by the Physiotherapist for an optimum recovery. You may have to take some time off work after surgery (usually 2 to 6 weeks) and will be able to resume driving when comfortable from 3 to 6 weeks after surgery. You may be able to work in 2-3 weeks (office work) or 6 to 8 weeks (manual labour or heavy lifting). Generally it can take 4 weeks for stationary cycling and 6 weeks for slow treadmill running.

Depending on the type of specific procedure performed during the arthroscopy, optimum time for recovery after hip arthroscopy can take anywhere between 6 weeks to 6 months. Recovery following hip arthroscopy heavily depends on the amount of damage to labrum and the articular cartilage found at the time of operation.

Complications of hip arthroscopy

Complications following hip arthroscopy are rare. Any surgical procedure on the hip joint carries small risk of injury to structures around the hip joint.

Possible risks of hip arthroscopy are:

• Injury to Nerves: Nerve injury is very rare after hip arthroscopy. Nerve injuries could     be related to the traction applied to the leg during the procedure. Sciatic nerve,     lateral cutaneous nerve of thigh (sensation of thigh) and pudendal nerve (sensation     of genitalia) may be affected. Injury to the nerves can cause pins and needles,     numbness etc. Majority of these nerve injuries are temporary.
• Injury to blood vessels: Injury to blood vessels are very rare
• Infection: Very rare
• Persistent pain: Some amount of pain may continue to persist after hip arthroscopy.     Pain relief after hip arthroscopy depends on the type of hip pathology and degree of     arthritis found in the hip joint at the time of operation.
• Anaesthetic risks
• Blood clots in the leg
• Other risks of any surgical procedure

Warning Signs: please contact Mr Samsani or his team immediately if you experience any of the following:

• Chills
• Fever
• Leakage from wounds
• Redness or warmth around hip
• Persistent or increasing pain in the thigh or calf
• Marked swelling of thigh or calf
• Loss of movement in leg