19.1 Introduction

Arthroscopic surgery of the hip is a relatively new field in orthopedics and has been rapidly gaining popularity due to less invasive means to address intra-articular pathology of the hip. The first use of hip arthroscopy was recorded by Burman in 1931. ¹ As newer technologies and diagnostics tools continue to develop and improve, practitioners now have a better understanding of hip pathology and the use of hip arthroscopy to treat these conditions.

19.2 Indications

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  Confirmed intra-articular hip pain unresponsive to conservative treatment

  
  
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  Femoroacetabular impingement (FAI). Three types (▶Fig. 19.1)

  
  
  
  
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    Cam. Abnormal/nonspherical femoral head impinges on the anterior-superior acetabulum; causes—anatomical/congenital (poor head-neck offset), posttraumatic, slipped capital femoral epiphysis (SCFE), femoral retroversion, coxa vara, femoral head avascular necrosis, and Legg-Calvé-Perthes disease

    
    
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    Pincer. Over coverage of the acetabulum anteriorly or acetabular retroversion; causes-coxa profunda, protrusio, and posttraumatic

    
    
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    Combined cam and pincer or mixed

  
  
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  Loose bodies/foreign bodies. Hip trauma, dislocation, femoral head fractures, penetrating trauma, synovial chondromatosis, osteoarthritis, and Legg-Calvé-Perthes disease

  
  
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  Labral lesions/tears (▶Fig. 19.2 ). Most common tears are anterosuperior or anterolateral.

  
  
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  Chondral lesions of the acetabulum or femoral head. Associated with labral tears

  
  
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  Synovial disease (pigmented villonodular synovitis, instability/capsular laxity)

19.3 Prognosis

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  Chondral lesion grade/loss is most predictive of surgical outcome.

  
  
  
  
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    Four Stages.

    
    
    
    
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      Stage 1. Free margin with intact cartilage.

      
      
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      Stage 2. Labral tears with subjacent femoral head.

    
    
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    Chondromalacia

    
    
    
    
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      Stage 3. 3A-labral tears with acetabular lesion <1 cm, 3B-labral tears with acetabular lesion >1 cm.

      
      
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      Stage 4. Labral tear with degenerative disease

19.4 Preop

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  Complete routine preoperative protocol. Review of history, physical examination, and imaging

  
  
  
  
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    History/exam. Groin pain or “C” sign, pain with prolonged sitting/flexion, clicking locking, positive impingement test-flexion adduction, and internal rotation

    
    
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    Plain radiograph (standing AP pelvis, AP/cross table lateral/false profile of hip). Assess for FAI, hip dysplasia, acetabular retroversion or cross-over sign, SCFE, Perthes disease, protrusio, coxa profunda, and osteoarthritis; can measure—lateral center edge angle, tonnis angle, acetabular index, and alpha angle.

    
    
    
    
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      MR arthrography (MRA) with gadolinium arthrography is best for assessing labral pathology, MRI on 3 Tesla magnet improving diagnostic accuracy.

  
  
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  Neurovascular structures in danger. Femoral nerve and artery anteriorly; lateral femoral cutaneous nerve (LFCN) anterolateral, sciatic nerve posteriorly, and gluteal nerve/vessels proximal/posteriorly

  
  
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  Surgical table/Patient position/Setup. General anesthesia, Hanna/fracture table, supine with operative side upper extremity over chest with oversized post between legs, fluoroscopy between legs, fluoroscopy monitor on operative side at patient’s head, and arthroscopy tower positioned opposite the operative leg (▶Fig. 19.3)