Hip Arthroscopy

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The first investigations into hip arthroscopy date back to the 1930s. ^{[1, 2]}  However, it was not until the 1980s that this procedure began its ascent as a mainstream hip treatment. ^[3]  The indications for hip arthroscopy have become considerably broader over the past 10 years, expanding to include not only intra-articular conditions but also various extra-articular processes and peripheral hip issues. ^[4] Outcomes may vary substantially, depending on the specific pathologic condition that the procedure is being performed to address. 

One of the most common indications for hip arthroscopy is management of femoroacetabular impingement (FAI) and associated labral tears. ^[5] Loose bodies, chondral pathology, degenerative joint disease, avascular necrosis (AVN), synovial disease, instability, internal and external snapping hip, and joint sepsis have all been treated with this approach in the literature. ^{[6, 7, 8]}  The application of hip arthroscopy to the treatment of extra-articular issues, including hip abductor tears and other peripheral and posterior compartment pathologic conditions, has expanded greatly as well. Arthroscopy has also been used after total hip arthroplasty and hip resurfacing in some cases. ^{[9, 10, 11]}

Careful patient selection is paramount for achieving good outcomes after hip arthroscopy. Systemic illness, local wounds, and infection are all contraindications for the procedure. Disorders that affect bone strength or restrict joint mobility may affect the ability to access the joint. Bone must be able to withstand the traction forces of the procedure, and the joint must be mobile enough to allow distraction and manipulation.

Advanced arthritis and degenerative joint disease may be contraindications, but the level of disease that a patient may have while remaining capable of being helped by surgical treatment is still a matter of debate. ^[12] Significant obesity may be a contraindication in some patients whose habitus exceeds the physical limits of the surgical instruments. ^{[7, 13, 8, 11]}

Proper portal placement for hip arthroscopy depends on an understanding of the anatomy about the hip. Anterior and medial structures to be taken into account include the femoral artery, the femoral vein, and the femoral nerve (see the images below); typically, these are 3.2 cm from the anterior portal. ^[14] Posteriorly, the sciatic nerve lies 2.9 cm from the posterior portal; it may be at risk if the portal drifts too far that direction. Superiorly, the superior gluteal nerve and artery lie 4.4 cm from the anterior and posterior lateral portals.

More anteriorly, the lateral femoral cutaneous nerve (LFCN; see the images below), along with its terminal branches, lies closer to a portal than any other significant neurovascular structure and is the most commonly affected nerve in terms of complications. A study by Byrd et al found that the anterior portal came within 0.3 cm of LFCN branches. ^{[14, 15]}

Because hip arthroscopy is still a relatively new procedure, opinions continue to vary with regard to several aspects of its performance. A 2015 article on best practices surveyed 27 high-volume hip arthroscopists and reported the following results ^[16] :

A systemic review that examined surgical treatment of FAI documented reduction of pain and improvement of function in 68-97% of patients. ^[17]  Success has also been reported in athletic populations, with 75% of athletes returning to the same level of competition. ^[18]  Many studies of long-term outcomes are currently under way. Although it has been theorized that surgical intervention may have an effect on the natural history of FAI as it relates to osteoarthritis of the hip, such intervention cannot be recommended for prophylaxis in asymptomatic hips. ^{[19, 20]}

Burman MS. Arthroscopy or the direct visualization of joints: an experimental cadaver study. J Bone Joint Surg Am. 1931 Oct. 13 (4):669-95.

Takagi K. The arthroscope: the second report. Journal of the Japanese Orthopedic Association. 1939. 14:441-66.

Glick JM. Hip arthroscopy by the lateral approach. Instr Course Lect. 2006. 55:317-23. [Medline].

Montgomery SR, Ngo SS, Hobson T, Nguyen S, Alluri R, Wang JC, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy. 2013 Apr. 29 (4):661-5. [Medline].

Stevens MS, Legay DA, Glazebrook MA, Amirault D. The evidence for hip arthroscopy: grading the current indications. Arthroscopy. 2010 Oct. 26 (10):1370-83. [Medline].

Smart LR, Oetgen M, Noonan B, Medvecky M. Beginning hip arthroscopy: indications, positioning, portals, basic techniques, and complications. Arthroscopy. 2007 Dec. 23 (12):1348-53. [Medline].

Byrd JW. Hip arthroscopy: surgical indications. Arthroscopy. 2006 Dec. 22 (12):1260-2. [Medline].

Byrd JW. Hip arthroscopy. J Am Acad Orthop Surg. 2006 Jul. 14 (7):433-44. [Medline].

Mei-Dan O, Pascual-Garrido C, Moreira B, McConkey MO, Young DA. The Role of Hip Arthroscopy in Investigating and Managing the Painful Hip Resurfacing Arthroplasty. Arthroscopy. 2015 Nov 6. [Medline].

McCarthy JC. The role of arthroscopy in THA: lessons learned. Bone Joint J. Feb 2015. 97-B (suppl 1):42.

Kelly BT, Williams RJ 3rd, Philippon MJ. Hip arthroscopy: current indications, treatment options, and management issues. Am J Sports Med. 2003 Nov-Dec. 31 (6):1020-37. [Medline].

Domb BG, Gui C, Lodhia P. How much arthritis is too much for hip arthroscopy: a systematic review. Arthroscopy. 2015 Mar. 31 (3):520-9. [Medline].

Bond JL, Knutson ZA, Ebert A, Guanche CA. The 23-point arthroscopic examination of the hip: basic setup, portal placement, and surgical technique. Arthroscopy. 2009 Apr. 25 (4):416-29. [Medline].

Byrd JW, Pappas JN, Pedley MJ. Hip arthroscopy: an anatomic study of portal placement and relationship to the extra-articular structures. Arthroscopy. 1995 Aug. 11 (4):418-23. [Medline].

Robertson WJ, Kelly BT. The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement. Arthroscopy. 2008 Sep. 24 (9):1019-26. [Medline].

Gupta A, Suarez-Ahedo C, Redmond JM, Gerhardt MB, Hanypsiak B, Stake CE, et al. Best Practices During Hip Arthroscopy: Aggregate Recommendations of High-Volume Surgeons. Arthroscopy. 2015 Sep. 31 (9):1722-7. [Medline].

Clohisy JC, St John LC, Schutz AL. Surgical treatment of femoroacetabular impingement: a systematic review of the literature. Clin Orthop Relat Res. 2010 Feb. 468 (2):555-64. [Medline].

Nho SJ, Magennis EM, Singh CK, Kelly BT. Outcomes after the arthroscopic treatment of femoroacetabular impingement in a mixed group of high-level athletes. Am J Sports Med. 2011 Jul. 39 Suppl:14S-9S. [Medline].

Collins JA, Ward JP, Youm T. Is prophylactic surgery for femoroacetabular impingement indicated? A systematic review. Am J Sports Med. 2014 Dec. 42 (12):3009-15. [Medline].

Bogunovic L, Nho S. Femoroacetabular impingement. Miller MD. Orthopedic Knowledge Update: Sports Medicine 5. 5th ed. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2016. 127-140.

Ward JP, Albert DB, Altman R, Goldstein RY, Cuff G, Youm T. Are femoral nerve blocks effective for early postoperative pain management after hip arthroscopy?. Arthroscopy. 2012 Aug. 28 (8):1064-9. [Medline].

Xing JG, Abdallah FW, Brull R, Oldfield S, Dold A, Murnaghan ML, et al. Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized, Triple-Masked Controlled Trial. Am J Sports Med. 2015 Nov. 43 (11):2680-7. [Medline].

Larson CM, Wulf CA. Intraoperative fluoroscopy for evaluation of bony resection during arthroscopic management of femoroacetabular impingement in the supine position. Arthroscopy. 2009 Oct. 25 (10):1183-92. [Medline].

Alpaugh K, Shin SR, Martin SD. Intra-articular Fluid Distension for Initial Portal Placement During Hip Arthroscopy: The “Femoral Head Drop” Technique. Arthrosc Tech. 2015 Feb. 4 (1):e23-7. [Medline].

Domb B, Hanypsiak B, Botser I. Labral penetration rate in a consecutive series of 300 hip arthroscopies. Am J Sports Med. 2012 Apr. 40 (4):864-9. [Medline].

Jackson TJ, Hammarstedt JE, Vemula SP, Domb BG. Acetabular Labral Base Repair Versus Circumferential Suture Repair: A Matched-Paired Comparison of Clinical Outcomes. Arthroscopy. 2015 Sep. 31 (9):1716-21. [Medline].

Domb BG, Philippon MJ, Giordano BD. Arthroscopic capsulotomy, capsular repair, and capsular plication of the hip: relation to atraumatic instability. Arthroscopy. 2013 Jan. 29 (1):162-73. [Medline].

Larson C, Clohisy J, Beaule P, et al. Complications after hip arthroscopy: A prospective, multicenter study using a validated grading classification. Arthroscopy. 2013. 29 (12 suppl):e204. [Full Text].

Malviya A, Raza A, Jameson S, James P, Reed MR, Partington PF. Complications and survival analyses of hip arthroscopies performed in the national health service in England: a review of 6,395 cases. Arthroscopy. 2015 May. 31 (5):836-42. [Medline].

Harris JD, McCormick FM, Abrams GD, Gupta AK, Ellis TJ, Bach BR Jr, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthroscopy. 2013 Mar. 29 (3):589-95. [Medline].

Polesello GC, Omine Fernandes AE, de Oliveira LP, Tavares Linhares JP, Queiroz MC. Medial hip arthroscopy portals: an anatomic study. Arthroscopy. 2014 Jan. 30 (1):55-9. [Medline].

Sardana V, Philippon MJ, de Sa D, Bedi A, Ye L, Simunovic N, et al. Revision Hip Arthroscopy Indications and Outcomes: A Systematic Review. Arthroscopy. 2015 Oct. 31 (10):2047-55. [Medline].

Bart Eastwood, DO Orthopedic Surgeon and Sports Medicine Specialist, Sideline Orthopedics and Sports Medicine

Bart Eastwood, DO is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Society for Sports Medicine, American Osteopathic Academy of Orthopedics, American Osteopathic Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Jennifer L Miller Medscape Editorial Staff

Disclosure: Nothing to disclose.

Dinesh Patel, MD, FACS Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital

Dinesh Patel, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons

Disclosure: Nothing to disclose.

Hip Arthroscopy

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