Chapter 31 Hip Arthroscopy

Theresa A. Chiaia, PT, Matthew D. Rivera, PT, MPT, CSCS

Hip arthroscopy has gained increased popularity over the past decade; however, it has undergone slow development compared to arthroscopy of the knee and shoulder. Knee and shoulder arthroscopy has evolved from open techniques, whereas the hip has not benefited from such early procedures. The advent of hip arthroscopy has led to improved recognition of intra-articular pathologies, which facilitated improved soft tissue diagnostic imaging techniques. This, in turn, has led to advances in hip arthroscopy techniques as a treatment for intra-articular lesions, including repair or excision of a torn labrum, removal of loose bodies, or repair of chondral lesions.

Injuries to the labrum are the most common source of hip pain identified at arthroscopy. The primary causes of these injuries are the result of femoral acetabular impingement or capsular laxity/hypermobility. Labral injury often results from repetitive motion in sports, such as golf, hockey, and soccer. Although traumatic tears are significantly less common, they are most common in high level athletes who participate in sports, such as football and skiing. The rehabilitation guidelines following hip arthroscopy for a torn labrum are presented here by the Hospital for Special Surgery.

Surgical Overview

• The labrum is a fibrocartilaginous rim that runs circumferentially around the perimeter of the acetabulum to the base of the fovea and becomes attached to the transverse acetabular ligament posteriorly and anteriorly.

• The labrum has many functions. It creates a seal enhancing joint lubrication, reinforces the acetabular rim contributing to joint stability, and plays a role in load distribution.

• The labrum is distinctively thinner in the anterior inferior portion and thicker posteriorly. The majority of labral tears occurs anteriorly.

• The labrum is predominately avascular, except the outermost layer that limits intrinsic healing.

• Free nerve endings and sensory organs have been identified within the labral tissue, which contributes to nociceptive and proprioceptive input.

• The goal of arthroscopic debridement of a torn labrum is to relieve the pain by removing the unstable flap that causes hip discomfort and addressing the underlying pathology.

1 The surgeon seeks to remove only torn labral tissue, leaving as much healthy intact labrum as possible.

2 If the underlying pathology is capsular laxity, thermal capsulorrhaphy and plication is indicated, whereas with femoral acetabular impingement, bony resection is recommended.

• The architectural constraints of the hip joint, as well as the proximity of the neurovascular structures, make arthroscopy of the hip more challenging than the shoulder.

1 Recent adaptations of flexible scopes and instruments designed for the hip have led to improved safety, visualization, and accessibility of this joint.

2 Distraction of the femoral head from the acetabulum, using 25 to 50 pounds of traction force, is necessary to visualize the articular surfaces.

• Typically, a three-portal approach is used.

1 The anterolateral portal is directly off the anterosuperior portion of the greater trochanter and penetrates the gluteus medius before entering the lateral capsule.

2 The anterior portal penetrates the sartorius and the rectus femoris and then enters the capsule. It presents the greatest risk to the lateral femoral neurovascular bundle.

3 The posterolateral portal is posterior to the tip of the greater trochanter, placing the sciatic nerve at risk of injury.

• A flexible chisel is used to cut the torn labrum, then a motorized shaver is used to complete the debridement.

• If the labrum is detached from the bone, a bioabsorbable suture anchor is placed on the rim of the acetabulum, and suture material is passed twice through the labrum.

• With femoral acetabular impingement, sequential removal of the osteophyte is performed, using the anterior scoping portal and distal lateral accessory portal.

• For capsular laxity, arthroscopic capsular plication of the iliofemoral ligament is performed following thermal modification of the capsule.

Rehabilitation Overview

• The rehabilitation program following hip arthroscopy for a torn labrum is initiated between 0 and 2 weeks postoperatively. The surgeon’s preference, the surgical procedure, and the intraoperative findings will guide the postoperative course.

• The rate of progression through rehabilitation will depend on the underlying condition of the joint and the chronicity of the impairments.

• A period of restrictive weight-bearing with an assistive device followed by progressive weight-bearing as tolerated is recommended to allow for adequate healing, decreased inflammation, and pain control.

• Control of pain and inflammation through activity modification is necessary for progression of function, especially in the early phase of rehabilitation.

• Hip range of motion (ROM) will be progressed within the surgeon’s designated parameters to allow for adequate healing and should be monitored to reduce joint compression forces and symptom provocation.

• The patient will follow a functionally-based progression with criteria for discharge, largely depending on the goals of the patient.

• The phases of rehabilitation represent a continuum rather than discrete, well-defined phases.

Postoperative Phase I (Day 1 to Week 4)

GOALS

• Communication with surgeon to gain understanding of intraoperative findings of the joint and provide insight into underlying causative factors

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