Courtesy: Oliver Marin-Pena, Madrid, Spain

Hip Arthroscopy and Hip Preservation Surgery: Current Concepts and Practical Pearls

Hip arthroscopy has become an increasingly important tool in the management of young adults with chronic hip and groin pain. Advances in imaging, surgical techniques, and understanding of hip biomechanics have expanded its indications. However, successful outcomes depend heavily on proper patient selection, accurate diagnosis, and meticulous surgical technique.

Introduction

Hip preservation surgery aims to relieve symptoms, improve function, and delay or prevent the development of osteoarthritis.

The ideal candidates are:

Young adults, typically under 50 years of age
Patients with chronic hip or groin pain
Individuals with correctable structural abnormalities

The most important principle in hip preservation surgery is:

Correct indication determines success.

Clinical Evaluation

History

Patients often present with:

Insidious onset hip or groin pain
Symptoms lasting months or years
Previous misdiagnoses such as:
- Lumbar spine pathology
- Hernias
- Sacroiliac joint disorders

A careful history is essential to identify the true pain source.

Physical Examination

General Assessment

Clinical examination should include:

Gait analysis
Single-leg stance testing
Assessment of hip range of motion
Evaluation of muscle strength

Important Clinical Findings

Reduced Global Range of Motion

Suggests:

Hip osteoarthritis
Advanced joint degeneration

Increased Range of Motion

May indicate:

Generalized ligamentous laxity
Hip hypermobility

Special Clinical Tests

Several examination maneuvers help localize pathology.

FADIR (Impingement Test)

Flexion, Adduction, Internal Rotation

Findings:

High specificity
Lower sensitivity
Positive test suggests femoroacetabular impingement (FAI)

Decompression Test

Relief of symptoms with traction suggests:

Intra-articular pathology

Dial Test

Used to assess:

Capsular laxity
Hip instability

Log Roll Test

Suggests:

Intra-articular hip pathology

FABER Test

Useful for evaluating:

Hip joint pathology
Sacroiliac joint disorders

Stinchfield Test

Assesses:

Intra-articular hip pain

Thomas Test

Evaluates:

Hip flexion contractures
Pelvic alignment

Important Clinical Pearl

Groin pain combined with a positive impingement test strongly suggests femoroacetabular impingement.

Treat the Patient, Not the Imaging

A critical concept in hip preservation surgery is the poor correlation between symptoms and imaging findings.

Research demonstrates that:

Many patients with hip pain have normal radiographs.
Many patients with radiographic osteoarthritis have little or no pain.

Therefore:

Imaging should support clinical findings.
Treatment decisions should never be based on imaging alone.

Differential Diagnosis of Hip Pain

Hip pain may originate from several structures.

Conditions That Must Be Excluded

Spine-Related Disorders

Lumbar radiculopathy
Lumbar spinal stenosis

Sacroiliac Joint Dysfunction

Can mimic intra-articular hip pain.

Knee Pathology

Pain may be referred to the hip or groin.

Greater Trochanteric Pain Syndrome

Includes:

Trochanteric bursitis
Gluteal tendinopathy

Deep Gluteal Syndrome

Compression of the sciatic nerve within the deep gluteal space.

Diagnostic Injections

An image-guided intra-articular injection can help determine whether symptoms originate from the hip joint.

Significant pain relief following injection supports:

Intra-articular pathology

The Importance of the Labrum

Functions of the Labrum

The acetabular labrum plays several important roles:

Maintains the fluid seal of the joint
Improves stability
Distributes load across the articular surface

Chondrolabral Junction

This is the transition zone between:

Articular cartilage
Acetabular labrum

It is often the first site of degeneration and injury.

Most labral tears occur alongside:

Chondral damage
Chondrolabral separation

Femoroacetabular Impingement (FAI)

Definition

FAI is a mechanical conflict between:

The femoral head-neck junction
The acetabular rim

Repeated impingement can lead to:

Labral tears
Cartilage damage
Early osteoarthritis

Types of Femoroacetabular Impingement

Cam-Type Impingement

Pathology

A bony prominence develops at the femoral head-neck junction.

Consequences

Abnormal contact during hip motion
Deep cartilage injury

Imaging Findings

Increased alpha angle
Alpha angle >55° is generally considered abnormal

Pincer-Type Impingement

Pathology

Excessive acetabular coverage of the femoral head.

Radiographic Findings

Crossover sign
Acetabular retroversion

Important Consideration

Pelvic tilt must be controlled during radiographic assessment because false-positive findings are common.

Mixed-Type Impingement

The most common form of FAI.

Features include:

Cam morphology
Pincer morphology

Present simultaneously.

Imaging Evaluation

Plain Radiographs

Essential views include:

AP Pelvis

Assesses:

Joint space
Coverage
Pelvic alignment

Dunn View

Useful for:

Cam lesions
Alpha angle measurement

Cross-Table Lateral View

Evaluates:

Head-neck offset

False Profile View

Assesses:

Anterior coverage

MRI and MR Arthrography

Helpful for evaluating:

Labral tears
Cartilage damage
Associated soft tissue pathology

MR arthrography may improve visualization of labral pathology.

Indications for Hip Preservation Surgery

Surgery should only be considered when all of the following are present:

Symptomatic patient
Clinical findings correlate with imaging
Failure of appropriate conservative treatment

Contraindications

Hip arthroscopy performs poorly in the presence of advanced degenerative disease.

Relative or Absolute Contraindications

Joint Space Less Than 2 mm

Associated with:

Higher failure rates
Increased conversion to total hip arthroplasty

Advanced Osteoarthritis

Poor outcomes after arthroscopy.

Surgical Options

Several joint-preserving procedures are available.

Hip Arthroscopy

Most commonly used for:

FAI correction
Labral repair
Chondral treatment

Surgical Hip Dislocation

Provides:

Complete visualization
Access to complex deformities

Mini-Open Techniques

Useful in selected situations.

Key Surgical Principles

Labral Preservation

Current evidence favors:

Labral repair
Labral reconstruction when necessary

Labral excision should be avoided whenever possible.

Rim Trimming

Should be conservative.

Excessive resection may result in instability.

Cam Osteoplasty

The goal is to:

Restore normal head-neck offset
Eliminate impingement

Complications

Failure to Improve

Approximately:

15% experience no significant improvement
5% may have worse outcomes

Traction-Related Complications

Potential complications include:

Nerve palsy
Perineal compression injuries
Temporary erectile dysfunction

Portal-Related Complications

Potential nerve injuries include:

Femoral nerve
Lateral femoral cutaneous nerve
Sciatic nerve (especially with posterior portals)

Surgical Technique Complications

Examples include:

Labral injury
Instrument breakage
Femoral neck fracture from excessive resection

Instability

May occur due to:

Excessive rim trimming
Capsular deficiency
Labral resection

Rare but Serious Complications

Avascular Necrosis

Rare but potentially devastating.

Fluid Extravasation

May lead to:

Abdominal distension
Intra-abdominal complications

Surgical Pearls

Several technical principles help optimize outcomes.

Joint Distraction

Apply adequate but not excessive traction
Use intermittent traction when possible

Capsular Management

Preserve the capsule whenever feasible
Repair when indicated

Labral Management

Repair rather than excise
Maintain the suction seal

Safe Resection Limits

Femoral Neck

Avoid resection exceeding:

30% of femoral neck diameter

Acetabular Rim

Avoid rim trimming greater than:

4 mm

Dysplasia and Hip Arthroscopy

Careful assessment of acetabular coverage is essential.

Lateral Center-Edge Angle (LCEA)

Less Than 20°

Generally indicates:

True dysplasia

Preferred treatment:

Periacetabular osteotomy (PAO)

20–25°

Borderline dysplasia

Hip arthroscopy may be considered with caution:

Avoid excessive rim trimming
Preserve the capsule
Maintain stability

Outcomes and Future Trends

Hip arthroscopy continues to grow worldwide.

However, conversion to total hip arthroplasty remains more likely in patients with:

Age greater than 50 years
Significant cartilage damage
Established osteoarthritis

Proper patient selection remains the most important determinant of long-term success.

Learning Curve

Hip arthroscopy has a significant learning curve.

Basic Competency

Approximately:

30 cases

Advanced Procedures

Require:

Additional experience
Cadaveric training
Structured mentorship

Key Take-Home Messages

Hip arthroscopy is primarily a joint-preserving procedure for young symptomatic patients.
Successful outcomes depend more on appropriate indications than on surgical technique alone.
Clinical findings, physical examination, and imaging must correlate before surgery is considered.
Labral preservation is critical for maintaining hip stability and function.
Avoid hip arthroscopy in patients with advanced osteoarthritis or joint space less than 2 mm.
Overcorrection can be as problematic as undercorrection.
Dysplasia requires careful evaluation, and many patients are better treated with periacetabular osteotomy rather than arthroscopy.
Patient selection remains the single most important factor in achieving durable results.

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