Hip Arthroscopy

Hip Scope Essentials - Peeking Inside Joint

• Minimally invasive surgical (MIS) procedure to diagnose & treat hip joint pathologies.
• Uses an arthroscope (small camera) & specialized instruments via small incisions (portals).
• Advantages: ↓ pain, ↓ blood loss, ↓ hospital stay, faster recovery vs open surgery.
• Key Anatomy: Acetabular labrum, femoral head-neck junction, articular cartilage, ligamentum teres.
• Portals: Anterolateral (AL), anterior (A), posterolateral (PL), distal anterolateral accessory (DALA).

⭐ Femoroacetabular Impingement (FAI) is a common indication for hip arthroscopy; Cam & Pincer types are key to differentiate for effective treatment planning and surgical correction inside the joint space and peripheral compartment respectively. 📌 CAM (Femoral) & PINCER (Acetabular).

Who Needs Scoping? - The Yes & No List

Indications (YES):

• FAI (Cam, Pincer)
• Labral tears
• Loose bodies
• Focal chondral defects
• Lig. teres tears
• Synovitis (diagnostic/therapeutic)
• Septic arthritis (lavage)
• Snapping hip (intra-articular)

Contraindications (NO):

• Advanced OA (Tönnis > 2 / joint space < 2 mm)
• Severe hip dysplasia
• Advanced AVN
• Active infection (non-septic arthritis context)
• Ankylosis / severe stiffness

⭐ Most common indication for hip arthroscopy is Femoroacetabular Impingement (FAI).

Setting the Stage - Portal Placement Playbook

• Positioning: Supine (commonest) or lateral decubitus.
• Traction: Crucial for joint access (8-10 mm distraction); perineal post or postless systems.
• Imaging: Fluoroscopy (C-arm) is mandatory for guiding portal placement safely.
• Standard Portals:
  • Anterolateral (AL): Often first, primary viewing.
  • Mid-Anterior (MA): Primary working portal.
  • Posterolateral (PL): Access to posterior compartment.
  • Distal/Proximal accessory portals as needed.
• Nerve Safety Zones:
  • Anterior: Femoral nerve/artery/vein, LFCN.
  • Posterior: Sciatic nerve.

  ⭐ The Lateral Femoral Cutaneous Nerve (LFCN) is the most frequently injured nerve during hip arthroscopy, especially via anterior portals.

Scope & Fix - Common Intra-op Hits

• FAI (Femoroacetabular Impingement):
  • Cam osteoplasty: Reshaping aspherical femoral head-neck junction.
  • Pincer acetabuloplasty: Trimming overcovered acetabular rim.
• Labral Tears:
  • Repair: Preferred for viable tissue using suture anchors.
  • Debridement: For irreparable or degenerative tears.
  • Reconstruction: Using autograft/allograft.
• Chondral Lesions:
  • Chondroplasty: Smoothing frayed cartilage.
  • Microfracture: For small (<2-4 cm²) full-thickness defects, stimulating marrow.
• Loose Body Removal: Extraction of free fragments.
• Synovitis: Targeted synovectomy for inflamed synovial tissue.
• Capsular Management: Plication for iatrogenic instability; capsulotomy/capsulectomy.

⭐ Most common indication: FAI, often coexisting with labral tears. Cam lesion (femoral) more common in young males.

After the Scope - Healing & Hazards

• Post-Op Recovery:
  • • Weight-bearing: Restricted (e.g., partial, crutches) 2-4 weeks, then progressive to full.
  • • Bracing: Common for labral repairs.
  • • Physiotherapy: Crucial from day 1: gentle ROM, progressing to strengthening exercises.
  • • Return to sport: 4-6 months, sport-specific.
• Complications (Hazards):
  • • Nerve palsies: Sciatic (most common, traction), LFCN (portals), Pudendal (perineal post).
  • • Iatrogenic: Chondral/labral injury.
  • • Fluid extravasation: Rare; risk: abdominal compartment syndrome.
  • • Infection: Rare (<1%).
  • • DVT/PE: Prophylaxis considered.
  • • Heterotopic Ossification (HO): Prophylactic NSAIDs (e.g., Indomethacin) for high-risk.
  • • Adhesions, persistent pain, instability.

⭐ Sciatic nerve neurapraxia is the most common neurological complication, often transient, related to traction time/force.

High‑Yield Points - ⚡ Biggest Takeaways

• Primary indications: Femoroacetabular Impingement (FAI) (cam/pincer), labral tears, loose bodies.
• Key portals: Anterolateral (AL) (initial viewing/instrumentation), Anterior (A), Postero-lateral (PL).
• Lateral Femoral Cutaneous Nerve (LFCN): Most common nerve injury, vulnerable with AL portal.
• Sciatic nerve at risk with PL portal; Femoral artery/nerve with Anterior portal.
• Traction is mandatory for joint access; can cause pudendal nerve neuropraxia or perineal complications.
• Major complications: Nerve injuries (LFCN, sciatic, pudendal), chondral damage, fluid extravasation, heterotopic ossification.
• Capsular closure is often performed to prevent iatrogenic instability and improve outcomes.