Courtesy: Dr Leandro Alves de Oliveira MD, COT Goiânia, Brazil
Hip Arthroscopy: Principles and Surgical Technique
Introduction
Hip arthroscopy is a minimally invasive surgical procedure used to diagnose and treat various intra-articular and periarticular hip disorders.
Common indications include:
- Femoroacetabular impingement (FAI)
- Labral tears
- Chondral lesions
- Loose bodies
- Synovial pathology
Hip arthroscopy has become increasingly important in the management of young adults with hip pain and mechanical symptoms.
Femoroacetabular Impingement (FAI)
Femoroacetabular impingement occurs due to abnormal contact between the femoral head-neck junction and the acetabulum.
Two major types are recognized:
Cam-Type FAI
Cam impingement is caused by:
- Abnormal bony prominence at the femoral head-neck junction
This leads to:
- Loss of femoral head-neck offset
- Abnormal shear forces
- Labral and cartilage injury
Pincer-Type FAI
Pincer impingement occurs due to:
- Acetabular overcoverage
This results in:
- Labral compression
- Acetabular rim overload
- Progressive chondrolabral damage
Case 1: Cam-Type Femoroacetabular Impingement
Clinical Features
Patients commonly present with:
- Progressive hip pain
- Groin pain
- Pain during flexion and internal rotation
- Positive impingement test
Mechanical symptoms may include:
- Clicking
- Catching
- Stiffness
Imaging Findings
X-Ray Findings
Plain radiographs may demonstrate:
- Loss of femoral head-neck offset
- Cam deformity
MRI Findings
MRI may reveal:
- Superior labral tear
- Chondral injury
- Increased alpha angle
Alpha Angle
An alpha angle greater than:
- 60°
is considered suggestive of cam-type impingement.
Surgical Technique for Cam-Type FAI
1. Patient Positioning
The patient is positioned:
- Supine on a traction table
Positioning typically includes:
- Approximately 10° hip flexion
- Internal rotation
Fluoroscopy is used to confirm:
- Adequate joint distraction
2. Portal Placement
Common Portals
Anterolateral Portal
Usually the:
- First portal established
Anterior Portal
Created under fluoroscopic and arthroscopic guidance.
Important Surface Landmarks
Portal placement is guided using:
- Greater trochanter
- Anterior superior iliac spine (ASIS)
3. Entry Technique
The outside-in technique is commonly used.
Steps of Portal Entry
Needle Insertion
A spinal needle is inserted into the joint.
Guidewire Placement
A guidewire is passed through the needle.
Skin Incision
A small incision is made.
Cannulated Dilator Insertion
Sequential dilation allows portal access.
4. Capsular Exposure
Soft tissue is cleared using:
- Arthroscopic shaver
The capsule appears as a:
- White fibrous structure
5. Capsulotomy
Capsulotomy improves visualization and instrument access.
Technique
A radiofrequency probe is commonly used to perform:
- Transverse capsulotomy
- Longitudinal capsulotomy
This exposes:
- Femoral head
- Labrum
- Head-neck junction
6. Cam Osteochondroplasty
Objective
The goal is to:
- Restore normal femoral head-neck offset
Procedure
The cam lesion is resected using:
- Arthroscopic burr
Fluoroscopy is essential to:
- Assess adequacy of resection
- Prevent under-resection or over-resection
Dynamic Assessment
The assistant may move the hip through:
- Internal rotation
- External rotation
- Flexion
to assess residual impingement.
7. Labral Management
Additional traction is applied to improve visualization of:
- Labral tears
- Chondral lesions
Labral Repair
Repair typically involves:
- Suture anchor placement
- Knot tying
- Restoration of the chondrolabral junction
Preservation and repair of the labrum are preferred whenever possible.
8. Final Steps
At the end of the procedure:
- Traction is released
- Hip motion is assessed
- Smooth femoral contour is confirmed
- Portals are closed
Surgical Outcome in Cam FAI
Successful surgery results in:
- Improved femoral head-neck contour
- Reduced impingement
- Improved hip motion
- Pain relief
Case 2: Pincer-Type Femoroacetabular Impingement
Clinical Features
Patients commonly present with:
- Hip pain
- Groin discomfort
- Positive impingement signs
Imaging Findings
X-Ray Findings
Radiographs may show:
- Acetabular overcoverage
- Crossover sign
- Labral calcification
MRI Findings
MRI may demonstrate:
- Labral tear
- Hypoplastic labrum
- Chondral injury
Surgical Technique for Pincer FAI
1. Capsular Exposure
Capsular exposure is performed similarly to the cam procedure.
2. Identification of Lesion
The surgeon identifies:
- Acetabular rim overcoverage
- Associated labral pathology
3. Acetabuloplasty
Objective
To correct:
- Excess acetabular rim prominence
Technique
A burr is used to trim the acetabular rim.
Care must be taken to avoid:
- Iatrogenic labral injury
4. Labral Detachment and Repair
The labrum may be:
- Detached temporarily
to allow adequate rim resection.
After acetabuloplasty:
- Suture anchors are placed
- Labrum is repaired back to the acetabular rim
5. Fixation Technique
Curved Cannulas
Curved cannulas facilitate:
- Better anchor trajectory
Non-Metallic Anchors
These are preferred because they:
- Reduce risk of cartilage injury
Final Outcome in Pincer FAI
Goals include:
- Restoration of acetabular contour
- Stable labral fixation
- Elimination of impingement
Intraoperative Pearls
Bleeding Control
Strategies include:
- Intravenous tranexamic acid preoperatively
- Adrenaline in irrigation fluid
- Radiofrequency coagulation
Traction Principles
- Minimal traction should be used
- Traction becomes easier after capsulotomy
- Fluoroscopic monitoring is essential
Nerve Safety
Prolonged traction may cause:
- Neuropraxia
Risk reduction strategies include:
- Limiting traction time
- Efficient surgical technique
- Careful positioning
Cartilage Management
Commonly Used Technique
Microfracture
Used for focal chondral defects.
The aim is to stimulate:
- Fibrocartilage formation
Advanced Cartilage Procedures
Less commonly available techniques include:
- Cartilage transplantation
- Biologic augmentation procedures
Postoperative Rehabilitation
Rehabilitation focuses on:
- Early motion
- Protection of repair
- Gradual strengthening
- Return to function
Return to sports is individualized based on:
- Extent of surgery
- Cartilage status
- Labral repair stability
Key Clinical Pearls
- Cam impingement results from abnormal femoral head-neck morphology.
- Pincer impingement results from acetabular overcoverage.
- Alpha angle greater than 60° suggests cam deformity.
- Labral preservation and repair are preferred over debridement.
- Fluoroscopy is essential during osteochondroplasty.
- Prolonged traction increases neuropraxia risk.
- Microfracture remains the most commonly used cartilage procedure.
Final Take-Home Message
Hip arthroscopy has become a valuable minimally invasive procedure for managing femoroacetabular impingement and associated intra-articular pathology.
Successful outcomes depend on:
- Accurate diagnosis
- Proper patient selection
- Anatomical correction of deformity
- Preservation of labral function
- Careful rehabilitation
Early treatment of FAI may help improve symptoms and reduce progression toward degenerative hip disease.
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