Arthroscopic Hip Labral Repair
Indications for Hip Arthroscopy
Since the early 20th century, when hip arthroscopy was regarded as being almost impossible to undertake, the procedure has developed in leaps and bounds. Presently there are many reasons why hip arthroscopy may be recommended. Perhaps the two most common current indications for hip arthroscopy include the presence of symptomatic FAI or an acetabular labral tear, or both.
Femoroacetabular Impingement (FAI)
FAI (or hip impingement) is a condition affecting the hip joint and is characterized by abnormal contact between the femoral head (hip ball) and the rim of the acetabulum (hip socket) leading to damage to the articular cartilage (lining) in the acetabulum, or to the labrum of the hip, or both. The labrum is a ring of cartilage that surrounds the acetabulum. Damage to the labrum and/or articular cartilage will likely cause pain. An abnormality in the shape of the femoral head or acetabulum, or both, may cause FAI. Activities that involve recurrent hip motion can increase the frequency of this abnormal contact.
FAI can affect all age groups from the early teens to throughout adult life, and is being increasingly recognized as one of the predisposing factors for osteoarthritis of the hip. While hip arthroscopy may reduce the chance of developing osteoarthritis, it does not eliminate it. Hip arthroscopy can be used to reshape the socket and/or the femoral head to prevent impingement, and aims to decrease the risk of developing osteoarthritis, as well relieving current painful symptoms.
Hip dysplasia, or a shallow acetabulum (socket), can increase the stress on the acetabular cartilage and labrum with regular or increased activities. With a shallow socket, some of the force that would normally be placed on the socket is transferred to the labrum, which can lead to a labral tear. In cases of mild or borderline dysplasia, repairing the labrum can relieve the painful symptoms within the hip with arthroscopy. However, it does not deepen the socket. A shallow socket can increase the risk of developing osteoarthritis in the hip. The goal of a hip arthroscopy would be relieving the current painful symptoms in the hip. It will not eliminate the risk of developing arthritis. In cases of advanced dysplasia, larger reconstructive surgeries (like a periacetabular osteotomy or PAO) is an option to increase the coverage.
Hip dysplasia and hip impingement are opposite ends of a spectrum (over-coverage versus under-coverage). Please check with me if you are unsure about your underlying diagnosis.
Acetabular Labral Tears
The labrum, which surrounds the acetabulum, can be partially damaged or torn. This is usually associated with FAI, but not always so. It can also occur with hip dysplasia (a shallow hip socket), after an injury or trauma, or even from over-use. With hip arthroscopy, the labrum can be either repaired, or in some cases debrided (remove the damaged tissue only). Occasionally a labrum can also be reconstructed with a graft. MRI and/or CT scans usually, but not always, reveal a labral tear.
Alternative Treatment Options
Surgery is the last option when all conservative management fails. However, other treatments are available. These vary from no treatment, just living with the condition, to physical therapy exercises, medication or injections.
Stem Cell Treatments
Stem cells are used in regenerative medicine to repair diseased or damaged tissues. While stem cell or PRP injections may not heal your hip on their own, there is emerging evidence that it can be used to augment and strengthen your surgical repair.
These treatments can be done during your surgery. Unfortunately, they are currently not covered by insurance. Please contact us if you would like more information or would like to include this with your surgery.
How We Perform Hip Arthroscopy
The bones of the hip joint (the ball and socket) are separated by approximately 1cm by applying traction to the foot while wearing a special boot. By distracting the hip, this provides enough room for a small telescope (‘arthroscope’) to be introduced into the joint. Initially, air and/or fluid are injected into the hip, under x-ray guidance. Once correct placement of the instrument has been confirmed, two, three, or sometimes four small incisions (portal sites) are made on the side of the hip. Each of these incisions generally measures approximately 5-10 mm in length.
Through these small portals, the arthroscope and instruments are passed into the joint. We will then be able to visualise the hip joint, identify the problem(s), and proceed appropriately. The operation duration will vary depending on the problem in the hip joint but can last from 40 minutes to 60 minutes, or even more. During the surgery, further x-rays may be taken, for example, to confirm adequate removal of bone.
At the end of the procedure, medications may be injected into the hip to minimize pain after the surgery. The small incisions are closed with sutures. Finally, a further dressing is placed over the incisions.
The surgery is almost always performed under general anesthesia. If a general anesthetic is given, then there may be an additional regional local anesthetic block.
Time in the Hospital
Patients enter the hospital in the morning, have the surgery and go home the same day. This is called outpatient surgery.
Using Ice or Heat After Surgery
Ice is recommended instead of heat. An ice pack should be applied to the hip (not directly on the skin) for at least 20 minutes, three times a day.
The use of a cold therapy device (e.g. PolarCare) device helps decrease pain and swelling after surgery. The use of the device may or may not be covered by the particular health insurance plan you have selected. You should check with your insurance company. It is optional to use. A cold-therapy device can also be purchased for you to own. Please contact us if you have questions about this.
After Hip Arthroscopy
Usually, you will feel some discomfort in your hip. In addition, the discomfort can be experienced in the lower back, buttock, knee and ankle. The discomfort can normally be reduced with appropriate pain medication. There is often some swelling and bruising in the groin, buttock and thigh. This is caused by the fluid used during the surgery. The swelling reduces over the following few days.
Depending on the procedures that were performed, you may be asked to limit the amount of weight you put through your operated leg. Consequently, you may require crutches for a few days, or weeks depending on what specific surgery has been performed. The specific amount of time with the crutches will be outlined in your protocol.
You will also use a brace for 4 weeks when walking that limits hip motion. It may be removed when bathing, exercising, sitting, and sleeping.
You will return to the clinic 10 to 14 days after the surgery for your first post-operative visit. At this appointment, your incisions may be inspected. The incisions are closed with buried sutures under the skin, so no sutures will need to be removed. A further explanation of the surgery will be provided and there will be an opportunity for specific queries to be answered. Any subsequent appointments will be arranged and will be guided by the surgery performed.
We will employ an appropriate rehabilitation program for you following the surgery, depending on the surgery performed. Your physical therapist will guide your return to sporting activities (running etc.) depending on your progress. This is extremely variable between individuals, depending on the surgical findings and the length of symptoms prior to surgery.
My personal feeling is that the goal of this operation is to eliminate or diminish pain and allow you to comfortably perform normal activities of daily living.
In the majority of cases, 6 to 8 weeks after surgery you should be walking relatively pain-free. Remember, however, that it may take 3 to 6 months (or more) to return to an elite level of competition/fitness. Any unexpected increase in pain can be treated with ice packs and anti-inflammatory medication.
There are some activities to avoid or take care with up to 8 weeks following surgery. These include the following:
- Prolonged standing, especially on hard surfaces.
- Prolonged walking i.e.; around shopping centres.
- Heavy lifting
- Squatting / crouching
- Sleeping on your side. Try to sleep on your back. If you must sleep on your side, sleep on the unoperated side, with a pillow under your operated leg – to hold that leg level with the body.
- Clutch use in manual cars (for left hips) – may flare up symptoms in the first couple of weeks and is best avoided. Exchange cars if possible.
Success of the Surgery
This type of surgery is successful about 85-90% of the time. No hip operation is 100% successful in every individual. The procedure are performed to will help restore the function in your hip. The operation is most successful at relieving pain. Approximately 80% of patients my patients say their pain is resolved, 15% say it is the same, and 5% say their pain is worse. What is harder to accomplish is the return to vigorous use of the leg in work and/or sports. Whether you can return to your previous level is an individual matter and depends on the damage to your hip, how well it heals, how well you rehabilitate and how strenuous is your desired level of work or sports. Because of the many variables involved I can make no guarantees other than to assure you I will deliver the very best medical care possible.
Potential Risks and Complications
All surgery carries risks, although every effort is made to minimize them. The complications can be temporary or permanent. Reassuringly, permanent complications following hip arthroscopy are rare and the majority are temporary. There are, however, risks which include the standard risks of undergoing general anaesthesia and specific risks associated with hip arthroscopy.
Complications have been reported to occur in up to 5% of patients and are most often related to temporary numbness/altered feeling in the groin and genitalia. This is due to a combination of distraction of the hip joint and pressure on the nerves in the groin at the time of surgery. This is uncommon and although there is a theoretical risk that this numbness could be permanent, in the majority the numbness recovers fully, usually within a few days. Other complications might include, but are not limited to: infection, fracture, increased pain, impotence, bleeding, nerve palsies, abandoned procedure, deep-vein thrombosis, instrument breakage, avascular necrosis of femoral head, extravasation of irrigation fluid, delayed wound healing, exacerbation of symptoms, development of arthritis, stiffness, need for further surgery, and the risk of anesthesia itself. However, many of these complications are extremely rare. For example, the exact rate of infection following hip arthroscopy is unknown, but would certainly appear to be substantially less than 1 in 1000.
My purpose in listing the types of complications that could possibly occur is to inform, not frighten you. While it would be preferable if we could perform surgery without any risk, this is not the case. The complications are rare (less than 1%) but regrettably, in spite of our best efforts, they do occur. I feel it is your right to know.
Returning to Work
For most office jobs I recommend 1-2 weeks off work. When you return to work your hip will be sore but you should be able to manage as long as you do no lifting, pushing, pulling or carrying. You will generally need 3 months before recovery is complete and return to heavy lifting There are no fixed rules for return to work. What I have described above are reasonable guidelines that I hope will help you and your employer ease your return to the workplace.
Pain Medication after Surgery
Your pain medication prescription will be given to you the day of surgery. Because of Texas laws and regulations, a written copy must be given as we cannot call in strong pain medication. Chantel will call in an anti-inflammatory to your local pharmacy before the surgery. You may also be started on Aspirin to prevent blood clots.
Please take your pain medication as directed. That means that you may take the pills every 3-4 hours as needed. Take the medicine with food in your stomach. Taking the medicine on an empty stomach can cause nausea. When you need more medication, call our office or your pharmacy to refill the prescription. We cannot do this after 5:00 PM, as no one will be in this office. We cannot refill narcotic medication on weekends. One of my colleagues at the Fondren Orthopedic Group is available 24 hours a day, 7 days a week but we ask that you restrict after hours and weekend call to emergencies only and let us handle less urgent problems during the week.
If You Have More Questions
Please contact us with further questions or to schedule a consultation.
Contact Dr. Gombera